Provider Demographics
NPI:1710663083
Name:MCDIFFITT, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MCDIFFITT
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 1:748 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2026
Mailing Address - Country:US
Mailing Address - Phone:681-302-0347
Mailing Address - Fax:
Practice Address - Street 1:748 4TH ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2026
Practice Address - Country:US
Practice Address - Phone:681-302-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV18212062228Medicaid
WV125553494Medicaid