Healthcare Provider Details

I. General information

NPI: 1710902614
Provider Name (Legal Business Name): MARY GORMAN BRESLIN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY GORMAN CASSIDY APRN

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 VINE ST B729
CINCINNATI OH
45220-2213
US

IV. Provider business mailing address

1 MOYER PL
CINCINNATI OH
45208-4423
US

V. Phone/Fax

Practice location:
  • Phone: 513-861-3100
  • Fax:
Mailing address:
  • Phone: 513-321-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3004326
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: