Healthcare Provider Details

I. General information

NPI: 1619261617
Provider Name (Legal Business Name): MITZI M WRIGHT AGPCNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 260
SAINT LOUIS MO
63128-3288
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 260
SAINT LOUIS MO
63128-3288
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5270
  • Fax: 314-543-5272
Mailing address:
  • Phone: 314-543-5270
  • Fax: 314-543-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2026015960
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60819909
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: