Provider Demographics
NPI:1073510764
Name:HARTLEY, MARY BETH (APRN)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505252
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5262
Mailing Address - Country:US
Mailing Address - Phone:620-688-6566
Mailing Address - Fax:620-688-6577
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-688-6566
Practice Address - Fax:620-688-6577
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45384363L00000X
MO121186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100446860GMedicaid
KS110385030OtherMEDICARE PTAN
KS100446860DMedicaid
P68888Medicare UPIN
KS100446860DMedicaid