Healthcare Provider Details

I. General information

NPI: 1346812708
Provider Name (Legal Business Name): DYLAN PIERCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR
ALTON IL
62002-6722
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7240
  • Fax: 618-463-7216
Mailing address:
  • Phone: 618-463-7240
  • Fax: 618-463-7216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209034376
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA03463
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: