Healthcare Provider Details

I. General information

NPI: 1245903863
Provider Name (Legal Business Name): ADRIENNE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BREEZE PARK DR.
WELDON SPRINGS MO
63304
US

IV. Provider business mailing address

5072 DOUGLAS PARK DR
SAINT PETERS MO
63304
US

V. Phone/Fax

Practice location:
  • Phone: 636-720-3090
  • Fax:
Mailing address:
  • Phone: 636-720-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010010977
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: