Provider Demographics
NPI:1205038320
Name:HERRIOTT, MARILYN JO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:JO
Last Name:HERRIOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7553 COUNTRY ROAD
Mailing Address - Street 2:#4
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515
Mailing Address - Country:US
Mailing Address - Phone:419-826-6500
Mailing Address - Fax:419-826-6500
Practice Address - Street 1:7553 COUNTRY ROAD
Practice Address - Street 2:#4
Practice Address - City:DELTA
Practice Address - State:OH
Practice Address - Zip Code:43515
Practice Address - Country:US
Practice Address - Phone:419-826-6500
Practice Address - Fax:419-826-6500
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 042114 MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2388812Medicaid