Provider Demographics
NPI:1588095590
Name:EPPERSON, MARY G (PNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:G
Last Name:EPPERSON
Suffix:
Gender:
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-6120
Mailing Address - Fax:314-454-4225
Practice Address - Street 1:13001 N OUTER 40 RD
Practice Address - Street 2:DIV NEUROLOGY PEDIATRICS, STE 1A
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5941
Practice Address - Country:US
Practice Address - Phone:314-454-6120
Practice Address - Fax:314-454-4225
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103040363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420011576Medicaid
MO1588095590Medicaid