Healthcare Provider Details

I. General information

NPI: 1225303522
Provider Name (Legal Business Name): KELLY DOUGHERTY WASSEL PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12360 MANCHESTER RD STE 100
SAINT LOUIS MO
63131-4302
US

IV. Provider business mailing address

12360 MANCHESTER RD STE 100
SAINT LOUIS MO
63131-4302
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8500
  • Fax: 314-996-4499
Mailing address:
  • Phone: 314-966-8500
  • Fax: 314-996-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2012006258
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: