MEDICARE: ROMAN HAILU FNP

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	R 206334-6	MN
2	363L00000X	Nurse Practitioner	2014019178	MO

General Provider Information

NPI Number	:	1538413794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROMAN HAILU FNP

Provider Business Mailing Address
First Line	:	11525 OLDE CABIN RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7146
Country	:	US
Telephone Number	:	314-997-0554
Fax Number	:

Provider Business Practice Location Address
First Line	:	11525 OLDE CABIN RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7146
Country	:	US
Telephone Number	:	314-997-0554
Fax Number	:

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

Provider Enumeration Date	:	11/08/2012
Last Update Date	:	10/23/2024

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