Healthcare Provider Details

I. General information

NPI: 1871925396
Provider Name (Legal Business Name): ELIZABETH COURTNY MUNGER R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 BOLTON DR APT C
BALLWIN MO
63011-5005
US

IV. Provider business mailing address

296 BOLTON DR APT C
BALLWIN MO
63011-5005
US

V. Phone/Fax

Practice location:
  • Phone: 618-444-5050
  • Fax:
Mailing address:
  • Phone: 618-444-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number2011014690
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: