Provider Demographics
NPI:1073610895
Name:BLEVINS, MARYANN B (NP)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:B
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3525 S NATIONAL AVE
Practice Address - Street 2:#105
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-840-0802
Practice Address - Fax:417-269-1098
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO083185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428408405Medicaid
181509OtherBLUE CROSS OF MO