1366477226 NPI number — REBECCA DEATHERAGE BUWALDA APRNBC

Table of content: REBECCA DEATHERAGE BUWALDA APRNBC (NPI 1366477226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366477226 NPI number — REBECCA DEATHERAGE BUWALDA APRNBC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUWALDA
Provider First Name:
REBECCA
Provider Middle Name:
DEATHERAGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRNBC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366477226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 955534
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63195-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR STE 600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-209-5100
Provider Business Practice Location Address Fax Number:
314-291-9508
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  FNP 124462 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P21556 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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