Healthcare Provider Details

I. General information

NPI: 1710234729
Provider Name (Legal Business Name): DIANA CHISHOLM ESTEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9415 OLD BONHOMME RD
SAINT LOUIS MO
63132-3406
US

IV. Provider business mailing address

9415 OLD BONHOMME RD
SAINT LOUIS MO
63132-3406
US

V. Phone/Fax

Practice location:
  • Phone: 314-494-7501
  • Fax:
Mailing address:
  • Phone: 314-494-7501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number091170
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: