Healthcare Provider Details

I. General information

NPI: 1225544109
Provider Name (Legal Business Name): HEATHER CHRISTINE LICATA PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER ALEXANDER

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD STE 120
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

615 S NEW BALLAS RD STE 120
SAINT LOUIS MO
63141-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6986
  • Fax: 314-251-5712
Mailing address:
  • Phone: 314-251-6986
  • Fax: 314-251-5712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2018005317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: