Healthcare Provider Details

I. General information

NPI: 1417294828
Provider Name (Legal Business Name): MARY ANNE LOFTIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 S EAST ST
MOUNT VERNON MO
65712-1331
US

IV. Provider business mailing address

1011 S EAST ST
MOUNT VERNON MO
65712-1331
US

V. Phone/Fax

Practice location:
  • Phone: 417-466-7191
  • Fax: 417-466-3876
Mailing address:
  • Phone: 417-466-7191
  • Fax: 417-466-3876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013000293
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1417294828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: