=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679964191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABBY CRONIN PEER AGNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2015
-----------------------------------------------------
Last Update Date | 03/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11500 OLIVE BLVD STE 235
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-925-0903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1093 ARBOR GROVE CT
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-4984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-603-3830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 2015001251
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------