Healthcare Provider Details

I. General information

NPI: 1669862348
Provider Name (Legal Business Name): DARRELL DEMARTINO FNP-BC, RN, EMT-P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DRIVE
BRIDGETON MO
63044
US

IV. Provider business mailing address

206 REDMOND PINES DR
WENTZVILLE MO
63385-4304
US

V. Phone/Fax

Practice location:
  • Phone: 517-242-1705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP-20168
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number3201009993
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704274228
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2016044503
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017002498
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704274228
License Number StateMI
# 7
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2017002497
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: