MEDICARE: DONNA THANH PHAN FNP-BC

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	363LF0000X	Family Nurse Practitioner	2014025348	MO
2	363L00000X	Nurse Practitioner	2015009124	MO

General Provider Information

NPI Number	:	1295129732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA THANH PHAN FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 955534
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-5534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9759 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-1346
Country	:	US
Telephone Number	:	636-669-2219
Fax Number	:

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

Provider Enumeration Date	:	03/23/2015
Last Update Date	:	08/21/2023

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Directions to “ DONNA THANH PHAN FNP-BC” Practice Location

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