Healthcare Provider Details

I. General information

NPI: 1841741030
Provider Name (Legal Business Name): EDWARD JIM VREDENBURGH III RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2016
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5000
  • Fax:
Mailing address:
  • Phone: 314-653-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018037132
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2001004428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: