MEDICARE: MARY CHARNIECE MADDOX LPN,RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	168309	OH
2	163W00000X	Registered Nurse	520981	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497239156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY CHARNIECE MADDOX LPN,RN

Provider Business Mailing Address
First Line	:	1073 THORNHILL DR
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2316
Country	:	US
Telephone Number	:	216-703-3320
Fax Number	:

Provider Business Practice Location Address
First Line	:	665 E 159TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-2413
Country	:	US
Telephone Number	:	216-703-3320
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	03/04/2024

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