Healthcare Provider Details

I. General information

NPI: 1750291266
Provider Name (Legal Business Name): DANIELLE BERTRAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 W EDGEWOOD DR STE 500
JEFFERSON CITY MO
65109-6952
US

IV. Provider business mailing address

4211 LANGHAM DR
COLUMBIA MO
65202-3342
US

V. Phone/Fax

Practice location:
  • Phone: 573-415-1009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026042202
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: