Healthcare Provider Details

I. General information

NPI: 1942957725
Provider Name (Legal Business Name): IRINA BAAZOV FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 DOUGHERTY FERRY RD STE 207
SAINT LOUIS MO
63122-3356
US

IV. Provider business mailing address

2325 DOUGHERTY FERRY RD STE 207
SAINT LOUIS MO
63122-3356
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-5002
  • Fax: 314-821-5029
Mailing address:
  • Phone: 314-821-5002
  • Fax: 314-821-5029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021050790
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: