Healthcare Provider Details

I. General information

NPI: 1952305807
Provider Name (Legal Business Name): MARY B BECKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 DUTCHMANS LN PLAZA III, SUITE 101
LOUISVILLE KY
40207-4707
US

IV. Provider business mailing address

2700 STANLEY GAULT PKWY STE 129
LOUISVILLE KY
40223-5132
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-8660
  • Fax: 502-896-5863
Mailing address:
  • Phone: 502-253-4917
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number3002137
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3002137
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: