Provider Demographics
NPI:1699756494
Name:UTTERMOHLEN, MARY AGNES (MSN, FNP-BC, RN-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:AGNES
Last Name:UTTERMOHLEN
Suffix:
Gender:F
Credentials:MSN, FNP-BC, RN-C
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:AGNES
Other - Last Name:STOTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN-FNP-BC, RN-C
Mailing Address - Street 1:3100 SCOFIELD ROAD #1179
Mailing Address - Street 2:FORT SAM HOUSTON PRIMARY CARE CLINIC
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-808-2470
Mailing Address - Fax:210-808-3515
Practice Address - Street 1:3100 SCOFIELD ROAD #1179
Practice Address - Street 2:FORT SAM HOUSTON PRIMARY CARE CLINIC
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-808-2470
Practice Address - Fax:210-808-3515
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX569973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily