Healthcare Provider Details

I. General information

NPI: 1316302730
Provider Name (Legal Business Name): THERESA GELVEN BSN, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-242-5912
  • Fax: 314-678-2181
Mailing address:
  • Phone: 314-242-5912
  • Fax: 314-678-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number093121
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: