Healthcare Provider Details

I. General information

NPI: 1235811274
Provider Name (Legal Business Name): AMANDA PEKAU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD STE 401
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

11125 DUNN RD STE 401
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-953-8100
  • Fax: 314-953-8050
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number2017023319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: