Healthcare Provider Details

I. General information

NPI: 1689388175
Provider Name (Legal Business Name): PAIGE COSMAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAIGE HENDERSON

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

4326 HAVEN ST
SAINT LOUIS MO
63116-2148
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-0175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209026479
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022037798
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: