Provider Demographics
NPI:1972645240
Name:NIELSEN, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:225 S MERAMEC AVE
Mailing Address - Street 2:SUITE 932T
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3511
Mailing Address - Country:US
Mailing Address - Phone:314-721-7550
Mailing Address - Fax:314-863-2114
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:SUITE 932T
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-721-7550
Practice Address - Fax:314-863-2114
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7P102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF31343Medicaid
11589908OtherCAQH
MO111963OtherBLUE CROSS
MO111963OtherBLUE CROSS