Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2018004474 | MO |
NPI | 1003323288 |
---|---|
Provider Name | Ms. Elizabeth Burton Walden- Prater |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Creve Coeur, MO 63141-6399 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2018 |
Last Update Date | 08/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
420051251 | (05) | MO |