Basic Information
| Provider Information | |||||||||
| NPI: | 1871946822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZAK | ||||||||
| FirstName: | MARY CLARE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCFADDEN | ||||||||
| OtherFirstName: | MARY CLARE | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD STE B | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193737607 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 W WOOSTER ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193526890 | ||||||||
| FaxNumber: | 4193532415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2016 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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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 | 363LP0200X | RN.384323 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | APRN.CNP.019560 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0180146 | 05 | OH | MEDICAID | APRN.CNP.019560 | 01 | OH | NURSE PRACTITIONER-OH BOARD OF NURSING | OTHER | RN.384323 | 01 | OH | OHIO BOARD OF NURSING | OTHER |