Healthcare Provider Details

I. General information

NPI: 1780120865
Provider Name (Legal Business Name): STACEY MELLIERE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

IV. Provider business mailing address

2730 SEDAN DR
SAINT LOUIS MO
63125-4054
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-5600
  • Fax:
Mailing address:
  • Phone: 314-249-6265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2016009690
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: