Healthcare Provider Details

I. General information

NPI: 1972774321
Provider Name (Legal Business Name): MARY LEBER D'ANGELO RNC, NNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY PATRICIA LEBER RN

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

8 WOODBRIDGE PARK RD
SAINT LOUIS MO
63131-4023
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6450
  • Fax:
Mailing address:
  • Phone: 314-580-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number079483
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number079483
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: