Healthcare Provider Details

I. General information

NPI: 1205980653
Provider Name (Legal Business Name): MARJORIE ANN MAHLE RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

8280 YANKEE ST
CENTERVILLE OH
45458-1806
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4331
  • Fax:
Mailing address:
  • Phone: 937-436-4658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA09531NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: