Provider Demographics
NPI:1598459992
Name:PRIDEMORE, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:PRIDEMORE
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 1:157 E FOREST ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:OH
Mailing Address - Zip Code:43410-2147
Mailing Address - Country:US
Mailing Address - Phone:567-230-3733
Mailing Address - Fax:
Practice Address - Street 1:157 E FOREST ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-2147
Practice Address - Country:US
Practice Address - Phone:567-230-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker