Provider Demographics
NPI:1386477834
Name:KING, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 WALL ST
Mailing Address - Street 2:
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1126
Mailing Address - Country:US
Mailing Address - Phone:573-701-6748
Mailing Address - Fax:
Practice Address - Street 1:3657 BAPTIST PARK RD
Practice Address - Street 2:
Practice Address - City:MAPAVILLE
Practice Address - State:MO
Practice Address - Zip Code:63065
Practice Address - Country:US
Practice Address - Phone:636-931-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004925164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse