Healthcare Provider Details

I. General information

NPI: 1972994309
Provider Name (Legal Business Name): NICOLE GUNDERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DEPAUL DRIVE
BRIDGETON MO
63044-2511
US

IV. Provider business mailing address

1127 CHILDRESS AVE
SAINT LOUIS MO
63139-3303
US

V. Phone/Fax

Practice location:
  • Phone: 314-809-1860
  • Fax:
Mailing address:
  • Phone: 314-809-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number2011025926
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: