Healthcare Provider Details

I. General information

NPI: 1528440807
Provider Name (Legal Business Name): OMNIA SALEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 N HANLEY RD
BERKELEY MO
63134-2003
US

IV. Provider business mailing address

450 CHUKKER VLY
ELLISVILLE MO
63021-2043
US

V. Phone/Fax

Practice location:
  • Phone: 314-615-0877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2015006765
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: