Healthcare Provider Details

I. General information

NPI: 1710540281
Provider Name (Legal Business Name): JAMIE PANOZZO CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

5920 HOLYOKE DR
SAINT LOUIS MO
63123-2714
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2010032877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: