Basic Information
| Provider Information | |||||||||
| NPI: | 1548435589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRETHOUR | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT - NCWY | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173262856 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 19TH STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059346600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1-075081 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.