Healthcare Provider Details

I. General information

NPI: 1679537112
Provider Name (Legal Business Name): MRS. NANCY IRENE RODENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS RD
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JEFFERSON BARRACKS RD 11F10-JB
SAINT LOUIS MO
63125-4181
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-5770
  • Fax: 314-894-5775
Mailing address:
  • Phone: 314-894-5770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number097588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: