Healthcare Provider Details

I. General information

NPI: 1225279946
Provider Name (Legal Business Name): TRACEY GIBSON RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR SUITE 100
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR SUITE 100
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-7150
  • Fax: 314-878-3051
Mailing address:
  • Phone: 314-878-7150
  • Fax: 314-878-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number123572
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: