Healthcare Provider Details

I. General information

NPI: 1184219339
Provider Name (Legal Business Name): DESIREE REINKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 ROSETTA DR
VILLA RIDGE MO
63089-1297
US

IV. Provider business mailing address

109 HIGHWAY AT
VILLA RIDGE MO
63089-2107
US

V. Phone/Fax

Practice location:
  • Phone: 636-402-8517
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10200667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: