Healthcare Provider Details

I. General information

NPI: 1760115257
Provider Name (Legal Business Name): MARY MENZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2022
Last Update Date: 07/03/2022
Certification Date: 07/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 RAINBOW LAKE RD
SIKESTON MO
63801-8752
US

IV. Provider business mailing address

180 RAINBOW LAKE RD
SIKESTON MO
63801-8752
US

V. Phone/Fax

Practice location:
  • Phone: 573-258-2886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number2018021926
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: