Healthcare Provider Details

I. General information

NPI: 1154725687
Provider Name (Legal Business Name): MARYELLEN SNIDER RN, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W JEFFERSON ST
SPRINGFIELD OH
45506-1224
US

IV. Provider business mailing address

1500 W JEFFERSON ST
SPRINGFIELD OH
45506-1224
US

V. Phone/Fax

Practice location:
  • Phone: 937-505-4179
  • Fax:
Mailing address:
  • Phone: 937-505-4179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN152935
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: