Healthcare Provider Details

I. General information

NPI: 1386569218
Provider Name (Legal Business Name): IZABELA FIDALA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CARDINAL WAY STE 900
SAINT LOUIS MO
63102-2807
US

IV. Provider business mailing address

6 CARDINAL WAY STE 900
SAINT LOUIS MO
63102-2807
US

V. Phone/Fax

Practice location:
  • Phone: 917-771-7295
  • Fax:
Mailing address:
  • Phone: 917-771-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number154222
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: