Provider Demographics
NPI:1679022438
Name:MILLER KROHN, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MILLER KROHN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3149
Mailing Address - Country:US
Mailing Address - Phone:314-703-1199
Mailing Address - Fax:
Practice Address - Street 1:10150 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2145
Practice Address - Country:US
Practice Address - Phone:414-431-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019629163W00000X
CA852028163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA852028OtherCALIFORNIA BOARD OF REGISTERED NURSING
MO2004019629OtherMISSOURI STATE BOARD OF NURSING