Provider Demographics
NPI:1235405622
Name:HARRIS, MIRLIE
Entity Type:Individual
Prefix:
First Name:MIRLIE
Middle Name:
Last Name:HARRIS
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 1:400 SUNSET CT
Mailing Address - Street 2:6F
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:OH
Mailing Address - Zip Code:45368-7619
Mailing Address - Country:US
Mailing Address - Phone:937-536-5435
Mailing Address - Fax:
Practice Address - Street 1:400 SUNSET CT
Practice Address - Street 2:6F
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:OH
Practice Address - Zip Code:45368-7619
Practice Address - Country:US
Practice Address - Phone:937-536-5435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400356920504376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide