Healthcare Provider Details

I. General information

NPI: 1144201708
Provider Name (Legal Business Name): MARY ANN MARRS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 S HIGHWAY 16
RAPID CITY SD
57702-8708
US

IV. Provider business mailing address

7220 S HIGHWAY 16 PO BOX 6850
RAPID CITY SD
57702-8708
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-1414
  • Fax: 605-341-7062
Mailing address:
  • Phone: 605-341-1414
  • Fax: 605-341-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR029403
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberSD-CNP CP000412
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: