Basic Information
| Provider Information | |||||||||
| NPI: | 1679769459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWATSKE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AHCNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | C B 8131 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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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 | 364SM0705X | 059839 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | IL | MEDICAID | 1679769459 | 05 | MO | MEDICAID |