Provider Demographics
NPI:1467840439
Name:TONINI, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TONINI
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 1:120 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4201
Mailing Address - Country:US
Mailing Address - Phone:502-855-3919
Mailing Address - Fax:
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-855-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008576363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
4813276OtherAETNA PIN
IN300009618Medicaid
000000993719OtherANTHEM PIN
KY7100408830Medicaid
CS1809600107OtherCARESOURCE ID