Healthcare Provider Details

I. General information

NPI: 1073700217
Provider Name (Legal Business Name): MISTY D WHEELOCK ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10050 KENNERLY RD STE 2400
SAINT LOUIS MO
63128-2193
US

IV. Provider business mailing address

10050 KENNERLY RD STE 2400
SAINT LOUIS MO
63128-2193
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-6066
  • Fax:
Mailing address:
  • Phone: 314-849-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number142467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: