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General NPI Number Information
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NPI Number | 1477952067
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Entity Type | Individual
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Provider Name | BRIANA WALDECK N.P.
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Gender | Female
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 5213 GODFREY RD STE 110
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City | GODFREY
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State | IL
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Zip | 62035-2510
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Country | US
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Telephone | 618-619-3330
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Fax | 618-619-3390
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Provider Business Mailing Address
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Address Line | 340 W LINCOLN ST SUITE 500
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City | BELLEVILLE
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State | IL
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Zip | 62220-1900
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Country | US
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Telephone | 618-277-7400
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Fax | 618-277-7422
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209011703
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License Number State | IL
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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 | 209011703
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License Number State | IL
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