Healthcare Provider Details

I. General information

NPI: 1053802538
Provider Name (Legal Business Name): PATRICE VALLOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8780
  • Fax: 314-577-8516
Mailing address:
  • Phone: 314-577-8780
  • Fax: 314-577-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021006509
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: