Healthcare Provider Details

I. General information

NPI: 1194899476
Provider Name (Legal Business Name): MARY LOU CHAPPELL NP CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 NORTH ST SUITE #4
AUBURN NY
13021-1852
US

IV. Provider business mailing address

17 LANSING ST AMMS, PC CREDENTIALING OFFICE
AUBURN NY
13021-1983
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-5028
  • Fax: 315-252-1587
Mailing address:
  • Phone: 315-255-7438
  • Fax: 315-255-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number307356-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420219-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF000976
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: