Provider Demographics
NPI:1205964038
Name:THIEL, MARY ALICE (CNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:THIEL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3544 PEBBLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2058
Mailing Address - Country:US
Mailing Address - Phone:513-313-8695
Mailing Address - Fax:
Practice Address - Street 1:26110 EMERY RD STE 300
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5788
Practice Address - Country:US
Practice Address - Phone:440-368-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.08370363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092977Medicaid
OHH205851Medicare PIN