Provider Demographics
NPI:1760948574
Name:HARTMAN, MILES W (PMHNP)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:W
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MERRIAM PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7096
Mailing Address - Country:US
Mailing Address - Phone:618-792-6522
Mailing Address - Fax:
Practice Address - Street 1:10420 OLD OLIVE STREET RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5914
Practice Address - Country:US
Practice Address - Phone:314-692-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-17
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019018504363LP0808X
MO2013038580163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health