Provider Demographics
NPI:1194390641
Name:WETHERHOLT, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:WETHERHOLT
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:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:OH
Mailing Address - Zip Code:45674-0136
Mailing Address - Country:US
Mailing Address - Phone:740-441-7062
Mailing Address - Fax:
Practice Address - Street 1:667 CHERRY RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:THURMAN
Practice Address - State:OH
Practice Address - Zip Code:45685
Practice Address - Country:US
Practice Address - Phone:740-441-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0375877Medicaid