Provider Demographics
NPI:1366579369
Name:OLDENBURGH, AILEEN GAIL
Entity type:Individual
Prefix:MRS
First Name:AILEEN
Middle Name:GAIL
Last Name:OLDENBURGH
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 1:5843 MELODY LANE
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3135
Mailing Address - Country:US
Mailing Address - Phone:440-257-1850
Mailing Address - Fax:440-257-1850
Practice Address - Street 1:5843 MELODY LN
Practice Address - Street 2:
Practice Address - City:MENTOR ON THE LAKE
Practice Address - State:OH
Practice Address - Zip Code:44060-3135
Practice Address - Country:US
Practice Address - Phone:440-257-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2432344Medicaid