Healthcare Provider Details

I. General information

NPI: 1508397910
Provider Name (Legal Business Name): RADA GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10018 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10018 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-7275
  • Fax:
Mailing address:
  • Phone: 314-525-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2014007149
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: