Healthcare Provider Details

I. General information

NPI: 1891415444
Provider Name (Legal Business Name): MARY LANESE CPD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3032 COKER DR
DAYTON OH
45440-2130
US

IV. Provider business mailing address

3032 COKER DR
DAYTON OH
45440-2130
US

V. Phone/Fax

Practice location:
  • Phone: 937-601-2273
  • Fax:
Mailing address:
  • Phone: 937-601-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: