Healthcare Provider Details

I. General information

NPI: 1982777413
Provider Name (Legal Business Name): DERMATOLOGY AT WINGHAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 WINGHAVEN BLVD STE 210
O FALLON MO
63368-3617
US

IV. Provider business mailing address

5551 WINGHAVEN BLVD STE 210
O FALLON MO
63368-3617
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-4613
  • Fax: 636-561-4610
Mailing address:
  • Phone: 636-561-4613
  • Fax: 636-561-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2004011011
License Number StateMO

VIII. Authorized Official

Name: DR. RACHEL M QUALLEY
Title or Position: PHYSICIAN,OWNER
Credential: M.D.
Phone: 636-561-4613