Healthcare Provider Details

I. General information

NPI: 1447607965
Provider Name (Legal Business Name): MARY MARGARET MULLANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 N OUTER 40 RD STE 320
TOWN AND COUNTRY MO
63017-5941
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-7337
  • Fax: 314-851-4476
Mailing address:
  • Phone: 314-567-7337
  • Fax: 314-851-4476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2016002940
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: