Provider Demographics
NPI:1760115257
Name:MENZ, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MENZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 RAINBOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-8752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 RAINBOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-8752
Practice Address - Country:US
Practice Address - Phone:573-258-2886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-03
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018021926163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO66383640Medicaid