Healthcare Provider Details

I. General information

NPI: 1659758860
Provider Name (Legal Business Name): MARY WELLER AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 YANKEE PARK PL
DAYTON OH
45458-1878
US

IV. Provider business mailing address

1504 YANKEE PARK PL
DAYTON OH
45458-1878
US

V. Phone/Fax

Practice location:
  • Phone: 937-424-3068
  • Fax: 937-496-5401
Mailing address:
  • Phone: 937-424-3068
  • Fax: 937-496-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN317029
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.18775-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: