Healthcare Provider Details

I. General information

NPI: 1467058636
Provider Name (Legal Business Name): MARY FAITH LEGRAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 S MADISON RD
MADISON OH
44057-9539
US

IV. Provider business mailing address

5517 S MADISON RD
MADISON OH
44057-9539
US

V. Phone/Fax

Practice location:
  • Phone: 440-298-1914
  • Fax:
Mailing address:
  • Phone: 440-298-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: