Provider Demographics
NPI:1649239484
Name:MAHONEY STOMBAUGH, SUSAN (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAHONEY STOMBAUGH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623
Mailing Address - Country:US
Mailing Address - Phone:419-479-5605
Mailing Address - Fax:
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623
Practice Address - Country:US
Practice Address - Phone:419-479-5605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP02288363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2524441Medicaid
OH2524441Medicaid
OHMANP05653Medicare ID - Type Unspecified