Healthcare Provider Details

I. General information

NPI: 1104220045
Provider Name (Legal Business Name): BIBIAN ONYEACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 LEWIS AND CLARK BLVD
SAINT LOUIS MO
63136-6005
US

IV. Provider business mailing address

2172 KEEVEN LN
FLORISSANT MO
63031-6502
US

V. Phone/Fax

Practice location:
  • Phone: 314-340-6389
  • Fax:
Mailing address:
  • Phone: 314-532-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number129858
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: