Provider Demographics
NPI:1659758860
Name:WELLER, MARY (AGPCNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 YANKEE PARK PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1878
Mailing Address - Country:US
Mailing Address - Phone:937-424-3068
Mailing Address - Fax:937-496-5401
Practice Address - Street 1:1504 YANKEE PARK PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-1878
Practice Address - Country:US
Practice Address - Phone:937-424-3068
Practice Address - Fax:937-496-5401
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN317029163WH0200X
OHCOA.18775-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WH0200XNursing Service ProvidersRegistered NurseHome Health