Healthcare Provider Details

I. General information

NPI: 1720620115
Provider Name (Legal Business Name): MARY ELLEN SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 2ND AVE
CHESAPEAKE OH
45619-1134
US

IV. Provider business mailing address

103 2ND AVE
CHESAPEAKE OH
45619-1134
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1551
  • Fax:
Mailing address:
  • Phone: 740-451-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.437947
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: