Healthcare Provider Details

I. General information

NPI: 1003459132
Provider Name (Legal Business Name): MARY E BOOTH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT JOSEPH DR
CENTERVILLE IA
52544-9017
US

IV. Provider business mailing address

1 SAINT JOSEPH DR
CENTERVILLE IA
52544-9017
US

V. Phone/Fax

Practice location:
  • Phone: 641-856-8684
  • Fax: 641-548-5233
Mailing address:
  • Phone: 641-437-3000
  • Fax: 641-437-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019031435
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA180897
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: