Provider Demographics
NPI:1215441308
Name:NEWSOME, MARY LOU
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9612
Mailing Address - Country:US
Mailing Address - Phone:740-439-0733
Mailing Address - Fax:
Practice Address - Street 1:61353 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-6607
Practice Address - Country:US
Practice Address - Phone:740-435-8585
Practice Address - Fax:740-435-2959
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
APRN.CNP.022015OtherCERTIFIED NURSE PRACTITIONER