Healthcare Provider Details

I. General information

NPI: 1770028078
Provider Name (Legal Business Name): MELISSA ANN BOMMARITO CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD ALLERGY/IMMUNOLOGY
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD ALLERGY/IMMUNOLOGY
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4014
  • Fax: 314-268-2712
Mailing address:
  • Phone: 314-268-4014
  • Fax: 314-268-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2016037790
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: