Healthcare Provider Details

I. General information

NPI: 1831632165
Provider Name (Legal Business Name): LEA-ANA RAE HODGES AGNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 12/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 WATSON ROAD
ST. LOUIS MO
63127
US

IV. Provider business mailing address

10345 WATSON ROAD
ST. LOUIS MO
63127
US

V. Phone/Fax

Practice location:
  • Phone: 314-384-3584
  • Fax: 314-965-6067
Mailing address:
  • Phone: 314-384-3584
  • Fax: 314-965-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016041030
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: