Healthcare Provider Details

I. General information

NPI: 1689762742
Provider Name (Legal Business Name): SHAWANA S BRANCH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWANA S BRANCH-ROWLES PNP

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 143-675-8203
  • Fax: 314-747-3338
Mailing address:
  • Phone: 143-675-8203
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number155025
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number155025
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: