Healthcare Provider Details

I. General information

NPI: 1710334040
Provider Name (Legal Business Name): MARY A MOULIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 METRO PL N STE 100
DUBLIN OH
43017-5343
US

IV. Provider business mailing address

525 METRO PL N STE 100
DUBLIN OH
43017-5343
US

V. Phone/Fax

Practice location:
  • Phone: 855-289-1722
  • Fax:
Mailing address:
  • Phone: 855-289-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberRN335272
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.335272
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.335272
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.335272
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: