Provider Demographics
NPI:1871631010
Name:LUMMIS, MARY B (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:LUMMIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:417-820-8852
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1871631010Medicaid
MO132680605Medicare PIN
MO1871631010Medicaid