Healthcare Provider Details

I. General information

NPI: 1093396087
Provider Name (Legal Business Name): ELIZABETH SIJO GEORGIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7419 WATSON RD
SAINT LOUIS MO
63119-4415
US

IV. Provider business mailing address

PO BOX 419052
SAINT LOUIS MO
63141-9052
US

V. Phone/Fax

Practice location:
  • Phone: 314-400-3360
  • Fax: 314-400-3363
Mailing address:
  • Phone: 314-851-1000
  • Fax: 314-851-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022045065
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: