Healthcare Provider Details

I. General information

NPI: 1407979594
Provider Name (Legal Business Name): MARY CATHERINE HEBERLE RN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

241 SMITH CREEK RD
WARRENTON MO
63383-6401
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6111
  • Fax:
Mailing address:
  • Phone: 636-932-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number047046
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: