Healthcare Provider Details

I. General information

NPI: 1417291493
Provider Name (Legal Business Name): CHANDRA M NOWLIS ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10448 OLD OLIVE STREET RD STE 200
SAINT LOUIS MO
63141-5927
US

IV. Provider business mailing address

10448 OLD OLIVE STREET RD STE 200
SAINT LOUIS MO
63141-5927
US

V. Phone/Fax

Practice location:
  • Phone: 314-597-8887
  • Fax: 314-447-9559
Mailing address:
  • Phone: 314-597-8887
  • Fax: 314-447-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2012037996
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: