Provider Demographics
NPI:1649336116
Name:PASS, MARYANN H (CNP)
Entity type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:H
Last Name:PASS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:H
Other - Last Name:KOPPERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DR
Mailing Address - Street 2:SUITE 122
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-465-2550
Mailing Address - Fax:618-462-4167
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:SUITE 122
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-465-2550
Practice Address - Fax:618-462-4167
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041272946163W00000X
MO123658163W00000X, 363L00000X
IL209001958363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner