Provider Demographics
NPI:1285233221
Name:PERYEA, MARY LOUISE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:PERYEA
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 1:225 S SANDUSKY ST LOT 65
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2660
Mailing Address - Country:US
Mailing Address - Phone:630-788-5766
Mailing Address - Fax:
Practice Address - Street 1:225 S SANDUSKY ST LOT 65
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2660
Practice Address - Country:US
Practice Address - Phone:630-788-5766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02124413747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant