Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036-111984 | IL |
Y | 207Q00000X | Family Doctor | 2004020480 | MO |
N | 207QS0010X | Family Doctor - Sports Medicine | 036.111984 | IL |
NPI | 1003893785 |
---|---|
Provider Name | Mrs. Jetuan L Rowley-Herron |
First Address | Saint Louis, MO 63112-4265 |
Second Address | Saint Louis, MO 63112-4265 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2005 |
Last Update Date | 30/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036111984 | (05) | IL |
I19950 | (02) |