Provider Demographics
NPI:1578260220
Name:COCKERHAM, MALLIE LENA
Entity Type:Individual
Prefix:MRS
First Name:MALLIE
Middle Name:LENA
Last Name:COCKERHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MALLIE
Other - Middle Name:LENA
Other - Last Name:COLLINSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 TOWNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6200
Mailing Address - Country:US
Mailing Address - Phone:513-423-5869
Mailing Address - Fax:513-423-6498
Practice Address - Street 1:2900 TOWNE BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6200
Practice Address - Country:US
Practice Address - Phone:513-423-5869
Practice Address - Fax:513-423-6498
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician