Provider Demographics
NPI:1053761627
Name:MIDDLETON, MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E SPRING VALLEY PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-2653
Mailing Address - Country:US
Mailing Address - Phone:937-436-3117
Mailing Address - Fax:937-436-0730
Practice Address - Street 1:7740 WASHINGTON VILLAGE DR
Practice Address - Street 2:STE 120
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4056
Practice Address - Country:US
Practice Address - Phone:937-439-7411
Practice Address - Fax:937-433-8030
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18955-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181525Medicaid
OHH342311Medicare PIN