Healthcare Provider Details

I. General information

NPI: 1164739710
Provider Name (Legal Business Name): MARY ELLEN KANTZ RN, BSN, CNOR, CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 ST. PETERS CENTRE BLVD RENAISSANCE PLASTIC SURGERY
ST. PETERS MO
63376
US

IV. Provider business mailing address

2909 W ADAMS
ST. CHARLES MO
63301-4603
US

V. Phone/Fax

Practice location:
  • Phone: 636-896-0600
  • Fax: 636-723-2000
Mailing address:
  • Phone: 636-724-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number044729
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number044729
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: