Healthcare Provider Details

I. General information

NPI: 1649735176
Provider Name (Legal Business Name): ALLYSON M GRANDEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DEPAUL DRIVE SUITE 205
SAINT LOUIS MO
63044-2727
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-218-2300
  • Fax: 314-646-1700
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2018038914
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: