Healthcare Provider Details

I. General information

NPI: 1982149878
Provider Name (Legal Business Name): ALLYSE MARIE ORTEGA FNP-C, AGACNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 WATERBURY FALLS DR STE B
O FALLON MO
63368-2208
US

IV. Provider business mailing address

844 WATERBURY FALLS DR STE B
O FALLON MO
63368-2208
US

V. Phone/Fax

Practice location:
  • Phone: 636-385-5556
  • Fax: 636-614-2093
Mailing address:
  • Phone: 636-385-5556
  • Fax: 636-614-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017001487
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2010020396
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2023000801
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: