Healthcare Provider Details

I. General information

NPI: 1508440041
Provider Name (Legal Business Name): WENDY S MATHER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 S BROADWAY
LORAIN OH
44053-3821
US

IV. Provider business mailing address

419 BOUNTY WAY
AVON LAKE OH
44012-2400
US

V. Phone/Fax

Practice location:
  • Phone: 440-233-7232
  • Fax:
Mailing address:
  • Phone: 216-401-1885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number383638
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: