Provider Demographics
NPI:1235726498
Name:BURDETTE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BURDETTE
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 1:9 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4008
Mailing Address - Country:US
Mailing Address - Phone:419-612-2066
Mailing Address - Fax:
Practice Address - Street 1:696 VILLA DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-4056
Practice Address - Country:US
Practice Address - Phone:419-512-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health