Healthcare Provider Details

I. General information

NPI: 1104303403
Provider Name (Legal Business Name): MARIJA GRGIC FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 SANTE FE CIR
ARNOLD MO
63010-5215
US

IV. Provider business mailing address

2105 SANTE FE CIR
ARNOLD MO
63010-5215
US

V. Phone/Fax

Practice location:
  • Phone: 314-602-9242
  • Fax:
Mailing address:
  • Phone: 314-602-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018022115
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: