Provider Demographics
NPI:1164739710
Name:KANTZ, MARY ELLEN (RN, BSN, CNOR, CRNFA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:KANTZ
Suffix:
Gender:F
Credentials:RN, BSN, CNOR, CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 W ADAMS
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-4603
Mailing Address - Country:US
Mailing Address - Phone:636-724-0031
Mailing Address - Fax:
Practice Address - Street 1:145 ST. PETERS CENTRE BLVD
Practice Address - Street 2:RENAISSANCE PLASTIC SURGERY
Practice Address - City:ST. PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-896-0600
Practice Address - Fax:636-723-2000
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044729163WR0006X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse