Provider Demographics
NPI:1679330419
Name:MAYBERRY, JONATHAN D (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11245 CLAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAPPINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63126-3415
Mailing Address - Country:US
Mailing Address - Phone:314-223-5850
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020871363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine