Provider Demographics
NPI:1487240214
Name:MOSS, STEPHANIE YVONNE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:YVONNE
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N 2ND ST APT C
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2294
Mailing Address - Country:US
Mailing Address - Phone:636-578-9223
Mailing Address - Fax:
Practice Address - Street 1:8011 CLAYTON RD STE 216
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1156
Practice Address - Country:US
Practice Address - Phone:314-260-7440
Practice Address - Fax:314-260-1196
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5379763052363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care