Healthcare Provider Details

I. General information

NPI: 1417351461
Provider Name (Legal Business Name): JESSICA LEE ROBERTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MCKELVEY RD
BRIDGETON MO
63044-2527
US

IV. Provider business mailing address

550 OAK COMMONS DR
BALLWIN MO
63021-6279
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-0911
  • Fax:
Mailing address:
  • Phone: 571-205-8774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2014037232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: