Unknown Individual – Family Nurse Practitioner, NPI 1629475934
Excluded from federal healthcare programs (Medicare/Medicaid)
This provider is listed on the OIG List of Excluded Individuals/Entities (LEIE). Exclusion effective: 2019-12-19. Reason: Felony conviction relating to controlled substance (mandatory; min. 5 years).
Family Nurse Practitioner
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Unknown Individual
319 PLEASANT RIDGE RD
FAIRVIEW HEIGHTS, IL 622081208
Phone: (814) 598-8284
Type: Mailing
3960 LINDELL BLVD
SAINT LOUIS, MO 631083204
Phone: (314) 652-0100
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
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Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
No Medicare enrollment or revalidation data available for this provider in our database.
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Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 62208)
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