Healthcare Provider Details

I. General information

NPI: 1912453945
Provider Name (Legal Business Name): DESIREE WICKENHAUSER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

V. Phone/Fax

Practice location:
  • Phone: 314-203-3041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041419907
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2011022892
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2017002698
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209016063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: