Healthcare Provider Details

I. General information

NPI: 1023471471
Provider Name (Legal Business Name): DEBORAH JEANETTE PARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 04/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10096 PAGE AVE
SAINT LOUIS MO
63132-1433
US

IV. Provider business mailing address

5346 MAPLE AVE
SAINT LOUIS MO
63112-3308
US

V. Phone/Fax

Practice location:
  • Phone: 314-494-6362
  • Fax:
Mailing address:
  • Phone: 314-494-6362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number085168
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: