Provider Demographics
NPI:1942896816
Name:DAUBENMIRE, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:DAUBENMIRE
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 1:25476 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:ROCKBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43149-9554
Mailing Address - Country:US
Mailing Address - Phone:740-407-2518
Mailing Address - Fax:
Practice Address - Street 1:25476 BUENA VISTA RD
Practice Address - Street 2:
Practice Address - City:ROCKBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43149-9554
Practice Address - Country:US
Practice Address - Phone:740-407-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3701495Medicaid
OH0330370Medicaid