Healthcare Provider Details

I. General information

NPI: 1649751462
Provider Name (Legal Business Name): AMANDA MARIE ANSON RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S NEW BALLAS RD STE 2030
SAINT LOUIS MO
63141
US

IV. Provider business mailing address

625 S NEW BALLAS RD STE 2030
SAINT LOUIS MO
63141-8253
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-1700
  • Fax: 314-251-1701
Mailing address:
  • Phone: 314-251-1700
  • Fax: 314-251-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2002006436
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018031883
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: