Healthcare Provider Details

I. General information

NPI: 1417982612
Provider Name (Legal Business Name): MARY ELLEN GOOD N.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 FORT AMANDA RD
LIMA OH
45804-3730
US

IV. Provider business mailing address

PO BOX 951999
CLEVELAND OH
44193-0021
US

V. Phone/Fax

Practice location:
  • Phone: 419-225-7301
  • Fax:
Mailing address:
  • Phone: 419-996-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN-093700 /NS04317
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: