Provider Demographics
NPI:1942413760
Name:OBERHOLTZER, MARY THEODORA (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THEODORA
Last Name:OBERHOLTZER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:THEODORA
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1540 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1011
Mailing Address - Country:US
Mailing Address - Phone:315-476-1771
Mailing Address - Fax:
Practice Address - Street 1:845 W GENESEE RD
Practice Address - Street 2:HOMECARE VARIES
Practice Address - City:PLAINVILLE
Practice Address - State:NY
Practice Address - Zip Code:13137
Practice Address - Country:US
Practice Address - Phone:315-638-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2844581163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01243998Medicaid