Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 2016022548 | MO |
NPI | 1003362021 |
---|---|
Provider Name | Stephanie Nellesen |
First Address | Saint Louis, MO 63141-8255 |
Second Address | Saint Louis, MO 63141-8255 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2016 |
Last Update Date | 16/11/2018 |