Basic Information
| Provider Information | |||||||||
| NPI: | 1649336116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PASS | ||||||||
| FirstName: | MARYANN | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOPPERMAN | ||||||||
| OtherFirstName: | MARYANN | ||||||||
| OtherMiddleName: | H. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184652550 | ||||||||
| FaxNumber: | 6184624167 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184652550 | ||||||||
| FaxNumber: | 6184624167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041272946 | IL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 123658 | MO | N | Nursing Service Providers | Registered Nurse | 363L00000X | 123658 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | 209001958 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.