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NPI Code Detail

MEDICARE: MARY BETH HARTLEY APRN

MEDICARE: MARY BETH HARTLEY APRN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner45384KS
2363LF0000XFamily Nurse Practitioner121186MO

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2110385030OTHERKSMEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1073510764
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY BETH HARTLEY APRN
Provider Business Mailing Address
First Line : PO BOX 505252
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63150-5262
Country : US
Telephone Number : 620-688-6566
Fax Number : 620-688-6577
Provider Business Practice Location Address
First Line : 1400 W 4TH ST
Second Line :
City : COFFEYVILLE
State : KS
Zip : 67337-3306
Country : US
Telephone Number : 620-688-6566
Fax Number : 620-688-6577
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2005
Last Update Date : 11/30/2016

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