Provider Demographics
NPI:1194710764
Name:WHITMAN, MARY (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:877-406-2662
Mailing Address - Fax:
Practice Address - Street 1:1501 SCHOOL RD
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9761
Practice Address - Country:US
Practice Address - Phone:877-406-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO094867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425198702Medicaid
P19537Medicare UPIN