Provider Demographics
NPI:1912978347
Name:FITZGERALD, MARILYN (RN, CS, AP/MHCNS)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:RN, CS, AP/MHCNS
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CS, AP/MHCNS
Mailing Address - Street 1:902 EDMOND ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64501-2702
Mailing Address - Country:US
Mailing Address - Phone:816-364-4300
Mailing Address - Fax:816-279-8148
Practice Address - Street 1:902 EDMOND ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501-2702
Practice Address - Country:US
Practice Address - Phone:816-364-4300
Practice Address - Fax:816-279-8148
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN089198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428517908Medicaid
MO428517908Medicaid