Provider Demographics
NPI:1508440041
Name:MATHER, WENDY S (RN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:S
Last Name:MATHER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 BOUNTY WAY
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2400
Mailing Address - Country:US
Mailing Address - Phone:216-401-1885
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH383638163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0Medicaid