Provider Demographics
NPI:1992764195
Name:MYERS, MARY ELLEN (RN, APRN-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:MYERS
Suffix:
Gender:F
Credentials:RN, APRN-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:AUBUCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, APRN-C
Mailing Address - Street 1:1694 VALERO LN
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3259
Mailing Address - Country:US
Mailing Address - Phone:314-540-0623
Mailing Address - Fax:844-848-6137
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-776-7999
Practice Address - Fax:844-848-6137
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN077928363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2500032240OtherBNDD-MISSOURI
MO2500032240OtherBNDD-MISSOURI