MEDICARE: RENEE CULLEN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	098909	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	098909	OTHER	MO	LICENSE

General Provider Information

NPI Number	:	1205187408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE CULLEN NP

Provider Business Mailing Address
First Line	:	1551 WALL ST
Second Line	:	SUITE 310
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3539
Country	:	US
Telephone Number	:	636-669-2268
Fax Number	:	314-209-8127

Provider Business Practice Location Address
First Line	:	10135 W FLORISSANT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2103
Country	:	US
Telephone Number	:	314-521-1444
Fax Number	:	314-521-2299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2012
Last Update Date	:	09/27/2012

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