Healthcare Provider Details

I. General information

NPI: 1356687131
Provider Name (Legal Business Name): SEAN EATHERTON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2012
Last Update Date: 12/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 WATSON RD
SAINT LOUIS MO
63119-4403
US

IV. Provider business mailing address

6875 FOXCROFT DR
SAINT LOUIS MO
63123-1635
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-8180
  • Fax:
Mailing address:
  • Phone: 314-832-1246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License Number2002016173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: