Provider Demographics
NPI:1427500909
Name:O'BRIEN, MARY LOU KATHLEEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY LOU
Middle Name:KATHLEEN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY LOU
Other - Middle Name:KATHLEEN
Other - Last Name:MOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:630 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-7519
Practice Address - Country:US
Practice Address - Phone:937-748-4211
Practice Address - Fax:937-748-3566
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020120363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily