MEDICARE: SREEKALA RADHAMANIAMMA DAVID DNP

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	163W00000X	Registered Nurse	041544395	IL
2	163W00000X	Registered Nurse	2010016856	MO
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2026009953	MO

General Provider Information

NPI Number	:	1790466829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SREEKALA RADHAMANIAMMA DAVID DNP

Provider Business Mailing Address
First Line	:	1061 WYNDGATE RIDGE DR
Second Line	:
City	:	LAKE SAINT LOUIS
State	:	MO
Zip	:	63367-4354
Country	:	US
Telephone Number	:	314-556-4822
Fax Number	:

Provider Business Practice Location Address
First Line	:	1061 WYNDGATE RIDGE DR
Second Line	:
City	:	LAKE SAINT LOUIS
State	:	MO
Zip	:	63367-4354
Country	:	US
Telephone Number	:	314-256-9557
Fax Number	:

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

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	04/19/2026

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