Provider Demographics
NPI:1316980717
Name:SMITH, MARY LYNN
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:SMITH
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 1:6401 GARBER RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2014
Mailing Address - Country:US
Mailing Address - Phone:937-898-0601
Mailing Address - Fax:937-898-0601
Practice Address - Street 1:6401 GARBER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2014
Practice Address - Country:US
Practice Address - Phone:937-898-0601
Practice Address - Fax:937-898-0601
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2144825Medicaid