1932628807 NPI number — NUTRESSA MONROE NURSE PRACTITIONER

Table of content: NUTRESSA MONROE NURSE PRACTITIONER (NPI 1932628807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932628807 NPI number — NUTRESSA MONROE NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONROE
Provider First Name:
NUTRESSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1932628807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 BEHLMANN ESTATES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORISSANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63034-2852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-808-0359
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12800 BOENKER LN
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:
63044-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-744-3444
Provider Business Practice Location Address Fax Number:
314-778-2448
Provider Enumeration Date:
09/12/2017

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:  2017023144 , 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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