Provider Demographics
NPI:1780082206
Name:CHANDLER, MARY (AANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:AANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S DIVISION ST
Mailing Address - Street 2:STE A
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1701
Mailing Address - Country:US
Mailing Address - Phone:573-454-2466
Mailing Address - Fax:573-454-2544
Practice Address - Street 1:11 S DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1701
Practice Address - Country:US
Practice Address - Phone:573-723-1100
Practice Address - Fax:572-723-1130
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019009110363LP0808X, 363LP0808X
MO2014044175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily