Provider Demographics
NPI:1417982612
Name:GOOD, MARY ELLEN (NS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GOOD
Suffix:
Gender:F
Credentials:NS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 951999
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0021
Mailing Address - Country:US
Mailing Address - Phone:419-996-5114
Mailing Address - Fax:
Practice Address - Street 1:2615 FORT AMANDA RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3730
Practice Address - Country:US
Practice Address - Phone:419-225-7301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-093700 /NS04317163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000200685OtherANTHEM BLUE CROSS
OHP22280Medicare UPIN