Provider Demographics
NPI:1295254266
Name:BETTENHAUSEN, MANDY ELIZABETH (AGNP)
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:ELIZABETH
Last Name:BETTENHAUSEN
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Gender:F
Credentials:AGNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:MSC 8109-43-1160
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-5298
Mailing Address - Fax:888-824-2176
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DIV SURG ACCS, STE 340
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-5298
Practice Address - Fax:888-824-2176
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2023-08-23
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Provider Licenses
StateLicense IDTaxonomies
MO2019008105363LG0600X, 363L00000X, 363LF0000X, 363LG0600X
MO2013005645208600000X
IL209024176363L00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420103116Medicaid