Healthcare Provider Details

I. General information

NPI: 1598099525
Provider Name (Legal Business Name): TECONDA LASHELLE DOUGLAS ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD STE 2427
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

11133 DUNN RD STE 2427
SAINT LOUIS MO
63136-6163
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-4275
  • Fax: 314-653-4376
Mailing address:
  • Phone: 314-653-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2000174039
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2000174039
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: