Healthcare Provider Details

I. General information

NPI: 1902652753
Provider Name (Legal Business Name): SHELBY FLORENCE MAIN CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/17/2025
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV PED ENDOCRINOLOGY AND DIABETES
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6051
  • Fax: 314-454-6225
Mailing address:
  • Phone: 314-454-6051
  • Fax: 314-454-6225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number2014025346
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: