Healthcare Provider Details

I. General information

NPI: 1376646513
Provider Name (Legal Business Name): MARY CAROL OBERHART APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2979 VICTORIA ST
BETTENDORF IA
52722-2784
US

IV. Provider business mailing address

2979 VICTORIA ST
BETTENDORF IA
52722-2784
US

V. Phone/Fax

Practice location:
  • Phone: 563-332-2253
  • Fax: 563-332-9331
Mailing address:
  • Phone: 563-332-2253
  • Fax: 563-332-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number113083
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: