Provider Demographics
NPI:1083377238
Name:HEFELE, MAURY ROSE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MAURY
Middle Name:ROSE
Last Name:HEFELE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BUOYANT PL
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3162
Mailing Address - Country:US
Mailing Address - Phone:573-673-4585
Mailing Address - Fax:
Practice Address - Street 1:38 BUOYANT PL
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3162
Practice Address - Country:US
Practice Address - Phone:573-673-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021040983363LP0808X
IAG166047363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health