Healthcare Provider Details

I. General information

NPI: 1134750342
Provider Name (Legal Business Name): HEATHER WELCH AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-3390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2020002812
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: