Healthcare Provider Details

I. General information

NPI: 1366477226
Provider Name (Legal Business Name): REBECCA DEATHERAGE BUWALDA APRNBC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DE PAUL DR STE 600
BRIDGETON MO
63044-2515
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-2510
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5100
  • Fax: 314-291-9508
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberFNP 124462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: