Healthcare Provider Details

I. General information

NPI: 1467592949
Provider Name (Legal Business Name): MARY LOUISE HEASLEY RN CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 GLENDON COURT VOC WORKS
DUBLIN OH
43016
US

IV. Provider business mailing address

11571 GARDEN LANE AVE NW
UNIONTOWN OH
44685
US

V. Phone/Fax

Practice location:
  • Phone: 614-760-3643
  • Fax: 614-760-3597
Mailing address:
  • Phone: 330-877-9525
  • Fax: 330-877-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRN 144241
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: