Healthcare Provider Details

I. General information

NPI: 1639650120
Provider Name (Legal Business Name): VALENTINA J MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY STE 206
O FALLON MO
63368-2207
US

IV. Provider business mailing address

20 PROGRESS POINT PKWY STE 206
O FALLON MO
63368-2207
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-1073
  • Fax: 636-344-1075
Mailing address:
  • Phone: 636-344-1073
  • Fax: 636-344-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018026928
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: