Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 076312 | MO |
NPI | 1003848516 |
---|---|
Provider Name | Debra E Solom |
First Address | Saint Louis, MO 63195-5534 |
Second Address | Bridgeton, MO 63044-2577 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 12/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P91300 | (02) | MO |