MEDICARE: MRS. MICHELE NEUDECKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	076292	MO

General Provider Information

NPI Number	:	1851381206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE NEUDECKER

Provider Business Mailing Address
First Line	:	6651 CHIPPEWA ST STE 322
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2532
Country	:	US
Telephone Number	:	314-457-9338
Fax Number	:	314-457-9341

Provider Business Practice Location Address
First Line	:	2325 DOUGHERTY FERRY RD STE 104
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3356
Country	:	US
Telephone Number	:	148-216-8893
Fax Number	:	314-457-9341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/28/2020

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