Healthcare Provider Details

I. General information

NPI: 1093586794
Provider Name (Legal Business Name): RENEE MARIE SIRTAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

23 MOUNTAIN LAUREL DR
SAINT PETERS MO
63376-2198
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-894-5775
Mailing address:
  • Phone: 636-248-2867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2000164723
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: