Provider Demographics
NPI:1518402445
Name:KOBERLEIN, MARY C (LD/N)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:KOBERLEIN
Suffix:
Gender:F
Credentials:LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S PROSPECT AVE APT O
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-9480
Mailing Address - Country:US
Mailing Address - Phone:330-388-6869
Mailing Address - Fax:
Practice Address - Street 1:1021 S PROSPECT AVE APT O
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9480
Practice Address - Country:US
Practice Address - Phone:330-388-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD7930133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist