Provider Demographics
NPI:1669142204
Name:MAYBERRY, LADAWN MARIE
Entity type:Individual
Prefix:
First Name:LADAWN
Middle Name:MARIE
Last Name:MAYBERRY
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 1:8021 MOUNT HOOD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-6935
Mailing Address - Country:US
Mailing Address - Phone:937-818-9134
Mailing Address - Fax:
Practice Address - Street 1:8021 MOUNT HOOD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-6935
Practice Address - Country:US
Practice Address - Phone:937-818-9134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3057329Medicaid