Healthcare Provider Details

I. General information

NPI: 1245180751
Provider Name (Legal Business Name): HAYLIE PHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 02/03/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 MAGNOLIA WAY
PEVELY MO
63070-1339
US

IV. Provider business mailing address

1940 MAGNOLIA WAY
PEVELY MO
63070-1339
US

V. Phone/Fax

Practice location:
  • Phone: 314-203-6468
  • Fax:
Mailing address:
  • Phone: 314-203-6468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95243342
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2019025077
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95243342
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: