Healthcare Provider Details

I. General information

NPI: 1487417689
Provider Name (Legal Business Name): IRIS PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 VETERANS MEMORIAL PKWY
SAINT CHARLES MO
63303-3526
US

IV. Provider business mailing address

2845 VETERANS MEMORIAL PKWY
SAINT CHARLES MO
63303-3526
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2017006157
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: