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General NPI Number Information
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NPI Number | 1245824226
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Entity Type | Organization
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Legal Business Name | PRO HEALTH ASSOCIATES, LLC
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Dates
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Enumeration Date | 02/21/2021
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Last Update Date | 01/15/2025
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Provider Practice Location Address
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Address Line | 4 DOBBS LN
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City | LAKE SAINT LOUIS
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State | MO
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Zip | 63367-4216
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Country | US
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Telephone | 636-385-3347
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 93
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City | WENTZVILLE
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State | MO
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Zip | 63385-0093
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Country | US
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Telephone | 636-385-3347
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTIONER, RN
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Name | MRS. VONDA GAIL GIBSON
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Credential | FNP-BC, RN
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Telephone | 636-385-3347
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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