Provider Demographics
NPI:1669840385
Name:KIDDEY, MARANDA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:ELIZABETH
Last Name:KIDDEY
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 1:16889 STATE ROUTE 45
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43968-9741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16889 STATE ROUTE 45
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43968-9741
Practice Address - Country:US
Practice Address - Phone:330-383-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program