Basic Information
| Provider Information | |||||||||
| NPI: | 1952305807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | STE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534917 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 DUTCHMANS LN | ||||||||
| Address2: | PLAZA III, SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028968660 | ||||||||
| FaxNumber: | 5028965863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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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 | 363LW0102X | 3002137 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 3002137 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78021375 | 05 | KY | MEDICAID |