Provider Demographics
NPI:1699817874
Name:GORNIAK, MARY RUTH (CNM, FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RUTH
Last Name:GORNIAK
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 SOUTHERN BELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6200
Mailing Address - Country:US
Mailing Address - Phone:937-426-8122
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-00786363LF0000X
OHNM-00661367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2190650Medicaid
OH2190650Medicaid