Healthcare Provider Details

I. General information

NPI: 1053782276
Provider Name (Legal Business Name): PHYLICIA LITTLE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 BOENKER LN
BRIDGETON MO
63044-2438
US

IV. Provider business mailing address

12800 BOENKER LN
BRIDGETON MO
63044-2438
US

V. Phone/Fax

Practice location:
  • Phone: 314-499-6060
  • Fax: 314-261-9222
Mailing address:
  • Phone: 314-499-6060
  • Fax: 314-261-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016027446
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009020513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: