Basic Information
| Provider Information | |||||||||
| NPI: | 1417982612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | N.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951999 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965114 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2615 FORT AMANDA RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458043730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192257301 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | RN-093700 /NS04317 | OH | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 000000200685 | 01 | OH | ANTHEM BLUE CROSS | OTHER |