Healthcare Provider Details

I. General information

NPI: 1316980717
Provider Name (Legal Business Name): MRS. MARY LYNN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 GARBER RD
DAYTON OH
45415-2014
US

IV. Provider business mailing address

6401 GARBER RD
DAYTON OH
45415-2014
US

V. Phone/Fax

Practice location:
  • Phone: 937-898-0601
  • Fax: 937-898-0601
Mailing address:
  • Phone: 937-898-0601
  • Fax: 937-898-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: