Healthcare Provider Details

I. General information

NPI: 1457134322
Provider Name (Legal Business Name): SHALEE BUENEMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 BOWLES AVE
FENTON MO
63026-2394
US

IV. Provider business mailing address

1587 RATHFORD DR
SAINT LOUIS MO
63146-3908
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-2000
  • Fax:
Mailing address:
  • Phone: 314-277-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number2019025504
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: