Healthcare Provider Details

I. General information

NPI: 1962882464
Provider Name (Legal Business Name): THELMA J SAMPSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 VETERANS MEMORIAL PKWY STE 200
SAINT CHARLES MO
63303-2106
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-669-2219
  • Fax:
Mailing address:
  • Phone: 636-498-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015010663
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: