Healthcare Provider Details

I. General information

NPI: 1629021597
Provider Name (Legal Business Name): ELIZABETH MULLANPHY JUDD CPNP, PMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-1833
US

IV. Provider business mailing address

2025 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-1833
US

V. Phone/Fax

Practice location:
  • Phone: 314-200-5778
  • Fax:
Mailing address:
  • Phone: 314-200-5778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1999140595
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License Number1999140595
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: