Healthcare Provider Details

I. General information

NPI: 1003977182
Provider Name (Legal Business Name): NANCY J CIBULKA WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE STE 341
SAINT LOUIS MO
63108-1402
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8064
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7882
  • Fax: 314-454-5167
Mailing address:
  • Phone: 314-454-7882
  • Fax: 314-454-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123136
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: