Healthcare Provider Details

I. General information

NPI: 1356449144
Provider Name (Legal Business Name): IMMACULA SAINT-LOUIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/27/2024
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 GREEN ST E
WILSON NC
27893-4105
US

IV. Provider business mailing address

303 GREEN ST E
WILSON NC
27893-4105
US

V. Phone/Fax

Practice location:
  • Phone: 252-243-9800
  • Fax:
Mailing address:
  • Phone: 252-243-9800
  • Fax: 252-243-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2005-01289
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number151877
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0088037
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005-01289
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: