Healthcare Provider Details

I. General information

NPI: 1720480015
Provider Name (Legal Business Name): MARISSA LEIGH SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S BRENTWOOD BLVD DIV NEUROLOGY SLEEP MED, STE 600
SAINT LOUIS MO
63144-1320
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8111
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1408
  • Fax: 314-747-4342
Mailing address:
  • Phone: 314-362-4342
  • Fax: 314-747-3813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021009802
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: