Healthcare Provider Details

I. General information

NPI: 1467285452
Provider Name (Legal Business Name): MADELEINE GRACE PEARSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 460A
SAINT LOUIS MO
63141-8259
US

IV. Provider business mailing address

2530 W 428TH RD
EAST PRAIRIE MO
63845-8835
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-4330
  • Fax:
Mailing address:
  • Phone: 573-683-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2024033994
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: