Provider Demographics
NPI:1699514521
Name:IBACH, MARY JUNE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JUNE
Last Name:IBACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:JUNE
Other - Last Name:AMERICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:104 PROCESS RD.
Mailing Address - Street 2:
Mailing Address - City:HEDGEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427
Mailing Address - Country:US
Mailing Address - Phone:301-471-7885
Mailing Address - Fax:
Practice Address - Street 1:900 VIRGINIA ST. EAST SUITE 500 MAXIM HEALTHCARE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:681-313-4759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP-14881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse