MEDICARE: MARY WELLER AGPCNP

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	163WH0200X	Home Health Registered Nurse	RN317029	OH
2	363L00000X	Nurse Practitioner	COA.18775-NP	OH

General Provider Information

NPI Number	:	1659758860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WELLER AGPCNP

Provider Business Mailing Address
First Line	:	1504 YANKEE PARK PL
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-1878
Country	:	US
Telephone Number	:	937-424-3068
Fax Number	:	937-496-5401

Provider Business Practice Location Address
First Line	:	1504 YANKEE PARK PL
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-1878
Country	:	US
Telephone Number	:	937-424-3068
Fax Number	:	937-496-5401

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

Provider Enumeration Date	:	04/27/2015
Last Update Date	:	08/29/2022

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