Healthcare Provider Details

I. General information

NPI: 1376101022
Provider Name (Legal Business Name): MARLENE WURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 STE GENEVIEVE AVE
FARMINGTON MO
63640
US

IV. Provider business mailing address

PO BOX 459
FARMINGTON MO
63640-0459
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-5749
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number110533
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: