Provider Demographics
NPI:1265475271
Name:SMITH, MARY ANNE (HHA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-2504
Mailing Address - Country:US
Mailing Address - Phone:440-593-4656
Mailing Address - Fax:
Practice Address - Street 1:452 MADISON ST
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2504
Practice Address - Country:US
Practice Address - Phone:440-593-4656
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2290560171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2290560Medicaid