Healthcare Provider Details

I. General information

NPI: 1659620102
Provider Name (Legal Business Name): ALEISHA ANN BREEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 DUNCAN AVE
SAINT LOUIS MO
63110-1111
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8111
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-658-3887
  • Fax: 314-286-8555
Mailing address:
  • Phone: 314-658-3887
  • Fax: 314-286-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20120149515
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: