Healthcare Provider Details

I. General information

NPI: 1932543527
Provider Name (Legal Business Name): KIMBERLY J PHELPS ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 EXECUTIVE PARKWAY DR SUITE 210
SAINT LOUIS MO
63141-6336
US

IV. Provider business mailing address

999 EXECUTIVE PARKWAY DR SUITE 210
SAINT LOUIS MO
63141-6336
US

V. Phone/Fax

Practice location:
  • Phone: 314-514-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2013011239
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: