Provider Demographics
NPI:1710334040
Name:MOULIN, MARY A (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MOULIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 METRO PL N STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5343
Mailing Address - Country:US
Mailing Address - Phone:855-289-1722
Mailing Address - Fax:
Practice Address - Street 1:525 METRO PL N STE 100
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5343
Practice Address - Country:US
Practice Address - Phone:855-289-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.335272163W00000X, 163WA0400X, 163WP0808X
OHRN335272324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid