Provider Demographics
NPI:1669061289
Name:CHRISTOPHERSEN, MARY CASEY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CASEY
Last Name:CHRISTOPHERSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CASEY
Other - Last Name:NIEZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0310
Practice Address - Street 1:205 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3900
Practice Address - Country:US
Practice Address - Phone:765-284-5389
Practice Address - Fax:765-284-5387
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28234514A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse