Provider Demographics
NPI:1346584687
Name:HUTSON, MARY ELIZABETH (CPNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:HUTSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BEVIRT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2515
Mailing Address - Country:US
Mailing Address - Phone:314-977-6828
Mailing Address - Fax:314-977-6872
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-4101
Practice Address - Fax:314-577-5379
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037995363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics