Healthcare Provider Details

I. General information

NPI: 1699083105
Provider Name (Legal Business Name): MARY JANE AUFDENGARTEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 HARVEY LN
ROLLA MO
65401-4576
US

IV. Provider business mailing address

1302 HARVEY LN
ROLLA MO
65401-4576
US

V. Phone/Fax

Practice location:
  • Phone: 573-341-8518
  • Fax: 573-596-0680
Mailing address:
  • Phone: 573-341-8518
  • Fax: 573-596-0680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number119175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: