Basic Information
| Provider Information | |||||||||
| NPI: | 1982188389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITHOELTER | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 931 GREEN BRIAR HILLS DR | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633665596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147995172 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143735740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2019033706 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.