Healthcare Provider Details

I. General information

NPI: 1669905642
Provider Name (Legal Business Name): MARIA DOLORES BUENAVENTURA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6209 FINN ROCK CIR
SAINT LOUIS MO
63128-4204
US

IV. Provider business mailing address

6209 FINN ROCK CIR
SAINT LOUIS MO
63128-4204
US

V. Phone/Fax

Practice location:
  • Phone: 314-456-3417
  • Fax:
Mailing address:
  • Phone: 314-456-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017006106
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: