Healthcare Provider Details

I. General information

NPI: 1790303493
Provider Name (Legal Business Name): CAROLINE GRACE NUGENT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16555 MANCHESTER RD STE 201
WILDWOOD MO
63040-1220
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-5858
  • Fax: 636-458-6510
Mailing address:
  • Phone: 636-458-5858
  • Fax: 636-458-6510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021042916
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2021042916
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: