Basic Information
| Provider Information | |||||||||
| NPI: | 1962725812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSLEY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED NURSE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEAGHER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3916 WINTHROP DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454313149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378295901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 160 N BREIEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450423806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139414999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2010 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN.132843-M-IV | OH | N | Nursing Service Providers | Licensed Practical Nurse | 163WP0809X | RN.401769 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.