Provider Demographics
NPI:1841272861
Name:CRECELIUS, MARY ELIZABETH (WHNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:CRECELIUS
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:573-883-4473
Mailing Address - Fax:573-883-4472
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9099
Practice Address - Country:US
Practice Address - Phone:573-483-2727
Practice Address - Fax:573-883-2463
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
MO089458363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428718712Medicaid
S39882Medicare UPIN
MO428718712Medicaid