Provider Demographics
NPI:1932142635
Name:BALLER, PATRICIA MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:BALLER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 E VALENTINE CIRCLE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-3155
Mailing Address - Country:US
Mailing Address - Phone:330-452-6060
Mailing Address - Fax:330-452-6065
Practice Address - Street 1:1470 E VALENTINE CIRCLE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-3155
Practice Address - Country:US
Practice Address - Phone:330-452-6060
Practice Address - Fax:330-452-6065
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNM-011104367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2211985Medicaid
OH000000186740OtherANTHEM
OHR03647Medicare UPIN