Provider Demographics
NPI:1750674099
Name:ANDERSON, MARY (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:ANDERSON
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 1:24366 BUSHBY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMINGVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43152-9712
Mailing Address - Country:US
Mailing Address - Phone:740-332-1549
Mailing Address - Fax:
Practice Address - Street 1:24366 BUSHBY RD
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMINGVILLE
Practice Address - State:OH
Practice Address - Zip Code:43152-9712
Practice Address - Country:US
Practice Address - Phone:740-332-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH338989163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health