Healthcare Provider Details

I. General information

NPI: 1073434163
Provider Name (Legal Business Name): STEPHANIE OLOMUKORO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13675 EVERGREEN GLEN DR
SAINT LOUIS MO
63128-4273
US

IV. Provider business mailing address

13675 EVERGREEN GLEN DR
SAINT LOUIS MO
63128-4273
US

V. Phone/Fax

Practice location:
  • Phone: 901-569-6062
  • Fax:
Mailing address:
  • Phone: 901-569-6062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2020016556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: