Provider Demographics
NPI:1144554270
Name:REILLY-GUTRIDGE, MOIRA A (LPN)
Entity type:Individual
Prefix:MS
First Name:MOIRA
Middle Name:A
Last Name:REILLY-GUTRIDGE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-2833
Mailing Address - Country:US
Mailing Address - Phone:614-315-6698
Mailing Address - Fax:
Practice Address - Street 1:2399 LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-2833
Practice Address - Country:US
Practice Address - Phone:614-315-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN052571164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse