Provider Demographics
NPI:1033224472
Name:FITZGERALD, MARY G (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:G
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2003
Mailing Address - Country:US
Mailing Address - Phone:314-615-0600
Mailing Address - Fax:314-615-8303
Practice Address - Street 1:6121 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2003
Practice Address - Country:US
Practice Address - Phone:314-615-0600
Practice Address - Fax:314-615-8303
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO065417363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425013323Medicaid
MO425013323Medicaid
MOP61676Medicare UPIN