Basic Information
| Provider Information | |||||||||
| NPI: | 1073510764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTLEY | ||||||||
| FirstName: | MARY BETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 505252 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206886566 | ||||||||
| FaxNumber: | 6206886577 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206886566 | ||||||||
| FaxNumber: | 6206886577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 45384 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 121186 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 100446860G | 05 | KS | MEDICAID | 110385030 | 01 | KS | MEDICARE PTAN | OTHER | 100446860D | 05 | KS | MEDICAID |