Healthcare Provider Details

I. General information

NPI: 1154305076
Provider Name (Legal Business Name): DEBRA BUBACK RN, MSN, ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR SUITE 375
SAINT LOUIS MO
63141-8635
US

IV. Provider business mailing address

12855 N 40 DR SUITE 375
SAINT LOUIS MO
63141-8635
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-6071
  • Fax: 314-567-7961
Mailing address:
  • Phone: 314-567-6071
  • Fax: 314-567-7961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number063206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: