Provider Demographics
NPI:1710254610
Name:TRAVER, MARY MADOLYN (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MADOLYN
Last Name:TRAVER
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 1:2200 JEFFERSON AVE
Mailing Address - Street 2:5TH FL CREDENTIAING DEPARTMENT
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:OH
Practice Address - Zip Code:43469-9723
Practice Address - Country:US
Practice Address - Phone:419-849-2871
Practice Address - Fax:419-849-3865
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN216511-COA1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082177Medicaid
OH0082177Medicaid