Provider Demographics
NPI:1992509368
Name:MAYBERRY, CASSANDRA
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1928
Mailing Address - Country:US
Mailing Address - Phone:317-918-3249
Mailing Address - Fax:
Practice Address - Street 1:2147 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1928
Practice Address - Country:US
Practice Address - Phone:317-918-3249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN376J00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemaker