Provider Demographics
NPI:1497239156
Name:MADDOX, MARY CHARNIECE (LPN,RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHARNIECE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LPN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 THORNHILL DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2316
Mailing Address - Country:US
Mailing Address - Phone:216-703-3320
Mailing Address - Fax:
Practice Address - Street 1:665 E 159TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2413
Practice Address - Country:US
Practice Address - Phone:216-703-3320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168309164X00000X
OH520981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH168398Medicaid