Healthcare Provider Details

I. General information

NPI: 1699817874
Provider Name (Legal Business Name): MARY RUTH GORNIAK CNM, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

624 SOUTHERN BELLE BLVD
BEAVERCREEK OH
45434-6200
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2007
  • Fax:
Mailing address:
  • Phone: 937-426-8122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-00786
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNM-00661
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: