Provider Demographics
NPI:1548435589
Name:BRETHOUR, MARY K (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:BRETHOUR
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT - NCWY
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-326-2856
Practice Address - Street 1:619 19TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL1-075081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208905173Medicare PIN