Healthcare Provider Details

I. General information

NPI: 1306024781
Provider Name (Legal Business Name): LAUREL A WIERSEMA BRYANT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ DIV SURG GENERAL
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8109-43-1160
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-2829
  • Fax: 314-362-5743
Mailing address:
  • Phone: 314-747-2829
  • Fax: 314-362-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number080003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: