Provider Demographics
NPI:1720494289
Name:PRIM, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PRIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PRIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:STNA
Mailing Address - Street 1:428 E 143RD ST APT 22
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1879
Mailing Address - Country:US
Mailing Address - Phone:216-704-7119
Mailing Address - Fax:
Practice Address - Street 1:3838 E 146TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1021
Practice Address - Country:US
Practice Address - Phone:216-296-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-06
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH601913700723376K00000X
OH0081238374U00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0081238Medicaid
OH601913700723OtherNURSE AIDE