Provider Demographics
NPI:1750833687
Name:WOODARD, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WOODARD
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:P O BOX 215
Mailing Address - Street 2:480 JERRY ST
Mailing Address - City:JERRY CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43437
Mailing Address - Country:US
Mailing Address - Phone:419-575-3792
Mailing Address - Fax:
Practice Address - Street 1:480 JERRY ST
Practice Address - Street 2:BOX 215
Practice Address - City:JERRY CITY
Practice Address - State:OH
Practice Address - Zip Code:43437
Practice Address - Country:US
Practice Address - Phone:419-575-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184386Medicaid