Healthcare Provider Details

I. General information

NPI: 1851721583
Provider Name (Legal Business Name): SUSAN HERENA ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE CITYPLACE DRIVE SUITE 570
SAINT LOUIS MO
63141-7067
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: 866-497-1239
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number26NR15225100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4182561
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: