Healthcare Provider Details

I. General information

NPI: 1588957294
Provider Name (Legal Business Name): ELISE SCHALLER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6036
  • Fax: 314-454-2604
Mailing address:
  • Phone: 314-454-6036
  • Fax: 314-454-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2011004389
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: