1073150017 NPI number — MRS. ZOE MARIE WADSWORTH APRN-CPNP

Table of content: MRS. ZOE MARIE WADSWORTH APRN-CPNP (NPI 1073150017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073150017 NPI number — MRS. ZOE MARIE WADSWORTH APRN-CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADSWORTH
Provider First Name:
ZOE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PREIS
Provider Other First Name:
ZOE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-CPNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073150017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1309 PINETREE LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-402-0129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DEPAUL DR SUITE 300
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-344-6021
Provider Business Practice Location Address Fax Number:
314-344-6131
Provider Enumeration Date:
12/10/2019

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: 363LP0200X , with the licence number:  2019011504 , 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)





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