Healthcare Provider Details

I. General information

NPI: 1346584687
Provider Name (Legal Business Name): MARY ELIZABETH HUTSON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY BEVIRT

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3691 RUTGER AVE
ST. LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4101
  • Fax: 314-577-5379
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2012037995
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: