Healthcare Provider Details

I. General information

NPI: 1588322069
Provider Name (Legal Business Name): STACIE CHAFFIN WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DES PERES RD STE 300
SAINT LOUIS MO
63131-2040
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 314-919-2600
  • Fax: 314-919-2677
Mailing address:
  • Phone: 314-919-2600
  • Fax: 314-919-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209022260
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2021023515
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: