Healthcare Provider Details

I. General information

NPI: 1902469075
Provider Name (Legal Business Name): STACIE MICHELLE WILSON AGNP-ACHPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 6017B
SAINT LOUIS MO
63141-8274
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 6017B
SAINT LOUIS MO
63141-8274
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7840
  • Fax:
Mailing address:
  • Phone: 314-251-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2019006496
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: