Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 065417 | MO |
NPI | 1033224472 |
---|---|
Provider Name | Mrs. Mary G Fitzgerald |
First Address | Berkeley, MO 63134-2003 |
Second Address | Berkeley, MO 63134-2003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 25/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
425013323 | (05) | MO |
P61676 | (02) | MO |