Healthcare Provider Details

I. General information

NPI: 1790610707
Provider Name (Legal Business Name): MRS. JUSTINA GLORIA WOLFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6119
US

IV. Provider business mailing address

11133 DUNN RD
SAINT LOUIS MO
63136-6119
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5000
  • Fax:
Mailing address:
  • Phone: 314-653-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2026026553
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: