Healthcare Provider Details

I. General information

NPI: 1295281236
Provider Name (Legal Business Name): ELIZABETH PEMBERTON AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 HARBOUR POINTE DR
GROVER MO
63040-1937
US

IV. Provider business mailing address

306 HARBOUR POINTE DR
GROVER MO
63040-1937
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-5424
  • Fax:
Mailing address:
  • Phone: 314-308-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016012215
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2016012215
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: