MEDICARE: MARY WIDENER LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LPN.130885.MEDS	OH

General Provider Information

NPI Number	:	1508589193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WIDENER LPN

Provider Business Mailing Address
First Line	:	1414 OAKLAND PARK AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-3507
Country	:	US
Telephone Number	:	614-389-3030
Fax Number	:	614-413-3536

Provider Business Practice Location Address
First Line	:	1414 OAKLAND PARK AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-3507
Country	:	US
Telephone Number	:	614-389-3030
Fax Number	:	614-413-3536

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2022
Last Update Date	:	09/20/2022

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