Provider Demographics
NPI:1235786856
Name:IMHANSIEMHONEHI, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:IMHANSIEMHONEHI
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 1:4568 ANTLER HILL DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-8704
Mailing Address - Country:US
Mailing Address - Phone:386-265-8778
Mailing Address - Fax:
Practice Address - Street 1:4568 ANTLER HILL DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-8704
Practice Address - Country:US
Practice Address - Phone:386-265-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities