Provider Demographics
NPI:1629052030
Name:MULLANEY-MAYNARD, DENISE J (ANP, ACNP)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:J
Last Name:MULLANEY-MAYNARD
Suffix:
Gender:F
Credentials:ANP, ACNP
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:J
Other - Last Name:MULLANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP, ACNP
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-953-6300
Mailing Address - Fax:314-953-6309
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE 2310C
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-953-6300
Practice Address - Fax:314-953-6309
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172414363L00000X
MO2013012825363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS51356Medicare UPIN