Healthcare Provider Details

I. General information

NPI: 1093252777
Provider Name (Legal Business Name): JILLIAN NICOLE ETHRIDGE-BROWN MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN NICOLE ETHRIDGE MSN, FNP-BC

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4438 TELEGRAPH RD
SAINT LOUIS MO
63129-3316
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-2235
US

V. Phone/Fax

Practice location:
  • Phone: 314-742-6000
  • Fax: 314-742-6002
Mailing address:
  • Phone: 314-742-6000
  • Fax: 314-742-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2016034571
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016034571
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2008021433
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041425190
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License Number2008021433
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: