Healthcare Provider Details

I. General information

NPI: 1831691401
Provider Name (Legal Business Name): MICHELLE ELIZABETH GRAGG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD STE 1400
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

4414 COVEFLOWER CT
LEBANON OH
45036-1759
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2018004246
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: