Healthcare Provider Details

I. General information

NPI: 1659450898
Provider Name (Legal Business Name): LISA GAYE DALEY APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

2617 IOWA ST
GRANITE CITY IL
62040-4806
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax:
Mailing address:
  • Phone: 618-876-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number155148
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: