Healthcare Provider Details

I. General information

NPI: 1811520455
Provider Name (Legal Business Name): LISA SELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N TUCKER BLVD
SAINT LOUIS MO
63101-1008
US

IV. Provider business mailing address

800 N TUCKER BLVD
SAINT LOUIS MO
63101-1008
US

V. Phone/Fax

Practice location:
  • Phone: 224-505-3279
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2018038899
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: