Healthcare Provider Details

I. General information

NPI: 1194132290
Provider Name (Legal Business Name): LISA BROOKS NURSE PRATITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

3639 OREGON AVE
SAINT LOUIS MO
63118-3805
US

V. Phone/Fax

Practice location:
  • Phone: 314-487-0400
  • Fax:
Mailing address:
  • Phone: 314-865-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2013027647
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: