Basic Information
| Provider Information | |||||||||
| NPI: | 1023309200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICKERMAN | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | APRN, ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144343278 | ||||||||
| FaxNumber: | 3145905949 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144343278 | ||||||||
| FaxNumber: | 3145905949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 2011006713 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.