Provider Demographics
NPI:1417971359
Name:CIESA, MARY ELLEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:CIESA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 HASKELL DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2826
Mailing Address - Country:US
Mailing Address - Phone:330-864-4536
Mailing Address - Fax:
Practice Address - Street 1:224 W EXCHANGE ST
Practice Address - Street 2:SUITE330
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1704
Practice Address - Country:US
Practice Address - Phone:330-344-6072
Practice Address - Fax:330-344-6447
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161987363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2062673Medicaid
OH2062673Medicaid
OHCINPO2221Medicare ID - Type Unspecified