Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2014037194 | MO |
NPI | 1972971794 |
---|---|
Provider Name | Amy O'connell |
First Address | Saint Louis, MO 63195-5534 |
Second Address | Wentzville, MO 63385-3826 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2015 |
Last Update Date | 13/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2014037194 | NP LICENSE (01) | MO |