Basic Information
| Provider Information | |||||||||
| NPI: | 1124177514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 DORR ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436154040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192913900 | ||||||||
| FaxNumber: | 4194796055 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 W CENTRAL AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192913900 | ||||||||
| FaxNumber: | 4194796055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN174693 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | RN174693 | 01 | OH | STATE LICENSE | OTHER | 2712327 | 05 | OH | MEDICAID |