Provider Demographics
NPI:1609119460
Name:OLDHAM, MARY ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:OLDHAM
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 1:12611 WESTPORT LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3417
Mailing Address - Country:US
Mailing Address - Phone:919-721-2693
Mailing Address - Fax:
Practice Address - Street 1:12611 WESTPORT LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3417
Practice Address - Country:US
Practice Address - Phone:919-721-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174H00000XOther Service ProvidersHealth Educator