Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 2019039962 | MO |
NPI | 1346889573 |
---|---|
Provider Name | Paige C Reque |
First Address | Sedalia, MO 65301-8956 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/01/2020 |
Last Update Date | 06/01/2020 |