Healthcare Provider Details

I. General information

NPI: 1306026190
Provider Name (Legal Business Name): DARREL ALAN HARRIS R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 PEQUENO LN
FENTON MO
63026-3673
US

IV. Provider business mailing address

1206 PEQUENO LN
FENTON MO
63026-3673
US

V. Phone/Fax

Practice location:
  • Phone: 636-861-7633
  • Fax: 636-861-7633
Mailing address:
  • Phone: 636-861-7633
  • Fax: 636-861-7633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number124205
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: