Healthcare Provider Details

I. General information

NPI: 1881836849
Provider Name (Legal Business Name): SAMANTHA LOUISE WATTS MARQUARD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9417 S BROADWAY
SAINT LOUIS MO
63125-2009
US

IV. Provider business mailing address

5501 DELMAR BLVD STE B560
SAINT LOUIS MO
63112-3084
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-4030
  • Fax: 314-833-4031
Mailing address:
  • Phone: 314-833-4030
  • Fax: 314-833-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2004018468
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: