Healthcare Provider Details

I. General information

NPI: 1790301232
Provider Name (Legal Business Name): MEGAN SAMANTHA KNETZER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 3900
O FALLON IL
62269-1282
US

IV. Provider business mailing address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-806-1770
  • Fax: 314-558-9017
Mailing address:
  • Phone: 314-806-1770
  • Fax: 314-558-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2021018970
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209030918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: