Healthcare Provider Details

I. General information

NPI: 1184091431
Provider Name (Legal Business Name): WOGENE AMSALU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9628 MIDLAND BLVD
OVERLAND MO
63114-3357
US

IV. Provider business mailing address

1131 INDIAN TRAILS DR
SAINT LOUIS MO
63132-3109
US

V. Phone/Fax

Practice location:
  • Phone: 314-779-6022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2018001284
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2002031108
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: