Healthcare Provider Details

I. General information

NPI: 1578866596
Provider Name (Legal Business Name): MISTY DAWN BIRNEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 LAMPLIGHTER SQR SHPPNG CTR SUITE J
SAINT LOUIS MO
63128-2761
US

IV. Provider business mailing address

12660 LAMPLIGHTER SQR SHPPNG CTR J
SAINT LOUIS MO
63128-2761
US

V. Phone/Fax

Practice location:
  • Phone: 314-394-1379
  • Fax: 314-394-1377
Mailing address:
  • Phone: 314-394-1379
  • Fax: 314-394-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2010041400
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: