1992764195 NPI number — MRS. MARY ELLEN MYERS RN, APRN-C

Table of content: MRS. MARY ELLEN MYERS RN, APRN-C (NPI 1992764195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992764195 NPI number — MRS. MARY ELLEN MYERS RN, APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
MARY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUBUCHON
Provider Other First Name:
MARY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, APRN-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992764195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1694 VALERO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63026-3259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-540-0623
Provider Business Mailing Address Fax Number:
844-848-6137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 S JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63118-3930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-776-7999
Provider Business Practice Location Address Fax Number:
844-848-6137
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  RN077928 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2500032240 . This is a "BNDD-MISSOURI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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