Provider Demographics
NPI:1467592667
Name:WALL, MARY JO (NP)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 GREENSVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-1882
Mailing Address - Country:US
Mailing Address - Phone:740-335-3433
Mailing Address - Fax:
Practice Address - Street 1:1227 U S ROUTE 22 S W
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1882
Practice Address - Country:US
Practice Address - Phone:740-333-3310
Practice Address - Fax:740-333-4303
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily