Healthcare Provider Details

I. General information

NPI: 1538764808
Provider Name (Legal Business Name): MARY SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 MAPLE CT
PLAIN CITY OH
43064-1188
US

IV. Provider business mailing address

328 MAPLE CT
PLAIN CITY OH
43064-1188
US

V. Phone/Fax

Practice location:
  • Phone: 614-314-5461
  • Fax:
Mailing address:
  • Phone: 614-314-5461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4901557
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: