Provider Demographics
NPI:1659432094
Name:CUNNINGHAM, MARY ANN (APN CRNFA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:APN CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 LAFAYETTE CT
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:314-277-1256
Mailing Address - Fax:
Practice Address - Street 1:345 LAFAYETTE CT
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:314-277-1256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO099273363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00323249Medicare PIN
P32090Medicare UPIN