Healthcare Provider Details

I. General information

NPI: 1780082206
Provider Name (Legal Business Name): MARY CHANDLER AANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 02/25/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S DIVISION ST STE A
BONNE TERRE MO
63628-1701
US

IV. Provider business mailing address

11 S DIVISION ST STE A
BONNE TERRE MO
63628-1701
US

V. Phone/Fax

Practice location:
  • Phone: 573-723-1100
  • Fax: 572-723-1130
Mailing address:
  • Phone: 573-454-2466
  • Fax: 573-454-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2014044175
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2019009110
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: