1467592949 NPI number — MRS. MARY LOUISE HEASLEY RN CCM

Table of content: MRS. MARY LOUISE HEASLEY RN CCM (NPI 1467592949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467592949 NPI number — MRS. MARY LOUISE HEASLEY RN CCM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEASLEY
Provider First Name:
MARY
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN CCM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467592949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11571 GARDEN LANE AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIONTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-877-9525
Provider Business Mailing Address Fax Number:
330-877-9533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6555 GLENDON COURT
Provider Second Line Business Practice Location Address:
VOC WORKS
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-760-3643
Provider Business Practice Location Address Fax Number:
614-760-3597
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  RN 144241 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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