Healthcare Provider Details

I. General information

NPI: 1225030117
Provider Name (Legal Business Name): TERESA M SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA M SMITH NP

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HIGHWAY K STE A
O FALLON MO
63366-8431
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-7213
US

V. Phone/Fax

Practice location:
  • Phone: 314-687-2730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number149531
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number149531
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16181-33
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number619816
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number614734
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: