Provider Demographics
NPI:1982188389
Name:WITHOELTER, MARY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WITHOELTER
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9354
Mailing Address - Country:US
Mailing Address - Phone:636-980-5300
Mailing Address - Fax:636-980-5344
Practice Address - Street 1:2630 STATE HIGHWAY K
Practice Address - Street 2:
Practice Address - City:OFALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-980-5300
Practice Address - Fax:636-980-5344
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019033706363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily