Healthcare Provider Details

I. General information

NPI: 1184175085
Provider Name (Legal Business Name): MISRAK GEBISSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SACKSTON WOODS LN
CREVE COEUR MO
63141-8228
US

IV. Provider business mailing address

10315 TUXFORD DR APT 10
SAINT LOUIS MO
63146-5825
US

V. Phone/Fax

Practice location:
  • Phone: 877-748-7030
  • Fax:
Mailing address:
  • Phone: 314-749-3615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAG0416096
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: