MEDICARE: MARY V CHANCE APN

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
1	2084P0800X	Psychiatry Physician	104029	MO

Other Identifiers

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

General Provider Information

NPI Number	:	1689635864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY V CHANCE APN

Provider Business Mailing Address
First Line	:	969 NORTHWYCK DR
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-3354
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 S 169 HWY
Second Line	:
City	:	SMITHVILLE
State	:	MO
Zip	:	64089-9317
Country	:	US
Telephone Number	:	816-461-8288
Fax Number	:	816-461-6586

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	03/28/2012

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Directions to “ MARY V CHANCE APN” Practice Location

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