Healthcare Provider Details

I. General information

NPI: 1477536456
Provider Name (Legal Business Name): REGINA LOUISE IMAN A.P.R.N.,B.C.,A.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DES PERES RD SUITE 300
SAINT LOUIS MO
63131-2050
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-919-2600
  • Fax: 314-919-2677
Mailing address:
  • Phone: 314-739-4166
  • Fax: 314-739-2485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberMO2002025105
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: