Provider Demographics
NPI:1487173654
Name:MEYER, EDMOND JAMES (BSN, RN, AE-C)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:JAMES
Last Name:MEYER
Suffix:
Gender:M
Credentials:BSN, RN, AE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2638 HIGHWAY 109 STE 100
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1161
Mailing Address - Country:US
Mailing Address - Phone:636-452-7689
Mailing Address - Fax:
Practice Address - Street 1:2638 HIGHWAY 109 STE 100
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1161
Practice Address - Country:US
Practice Address - Phone:636-452-7689
Practice Address - Fax:636-452-7689
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6086174H00000X
MO151689163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151689OtherMISSOURI STATE BOARD OF NURSING