Healthcare Provider Details

I. General information

NPI: 1073041760
Provider Name (Legal Business Name): AMANDA HEISEL NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 PATIENTS FIRST DR STE 3400
WASHINGTON MO
63090-4700
US

IV. Provider business mailing address

197 CREEK BOTTOM RD
LABADIE MO
63055-1121
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-5155
  • Fax: 636-239-1478
Mailing address:
  • Phone: 314-974-5017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2017010492
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2017010492
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2017010492
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: