Healthcare Provider Details

I. General information

NPI: 1306827159
Provider Name (Legal Business Name): MARY ELLEN YEMM-SHORES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 DOUGHERTY FERRY RD
SAINT LOUIS MO
63122-3313
US

IV. Provider business mailing address

13523 BARRETT PARKWAY DR SUITE 210
BALLWIN MO
63021-3802
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-5850
  • Fax:
Mailing address:
  • Phone: 314-775-2816
  • Fax: 314-775-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number070055
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: