Basic Information
| Provider Information | |||||||||
| NPI: | 1427500909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MARY LOU | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOYER | ||||||||
| OtherFirstName: | MARY LOU | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450667519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | 9377483566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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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 | 363LF0000X | APRN.CNP.020120 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.