Healthcare Provider Details

I. General information

NPI: 1184074270
Provider Name (Legal Business Name): AUTUMN ROQUE DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

IV. Provider business mailing address

4130 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-5600
  • Fax:
Mailing address:
  • Phone: 314-535-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2016019122
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: