Healthcare Provider Details

I. General information

NPI: 1649336116
Provider Name (Legal Business Name): MARYANN H. PASS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYANN H. KOPPERMAN

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR SUITE 122
ALTON IL
62002-6723
US

IV. Provider business mailing address

2 MEMORIAL DR SUITE 122
ALTON IL
62002-6723
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-2550
  • Fax: 618-462-4167
Mailing address:
  • Phone: 618-465-2550
  • Fax: 618-462-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number123658
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209001958
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041272946
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number123658
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: