=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245123330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA MAYBERRY FNP-BC NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2025
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4625 LINDELL BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-854-0410
-----------------------------------------------------
Fax | 573-552-4536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 SUNWARD DR
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-6939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-825-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2025014200
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------