Provider Demographics
NPI:1164039871
Name:PROCTOR, MARIAH
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 VANDIVER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-3948
Mailing Address - Country:US
Mailing Address - Phone:573-814-8528
Mailing Address - Fax:
Practice Address - Street 1:1809 VANDIVER DR STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3948
Practice Address - Country:US
Practice Address - Phone:573-814-8528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-26
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health