Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2018010406 | MO |
N | 363LF0000X | Nurse Practitioner - Family Medicine | 2018010406 | MO |
NPI | 1003303389 |
---|---|
Provider Name | Holly Ackermann |
First Address | Saint Louis, MO 63195-2551 |
Second Address | Saint Louis, MO 63119-5218 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2018 |
Last Update Date | 19/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2018010406 | MO STATE LICENSE (01) | MO |