Basic Information
| Provider Information | |||||||||
| NPI: | 1053617589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | AMIE | ||||||||
| MiddleName: | MELISSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPRUELL | ||||||||
| OtherFirstName: | AMIE | ||||||||
| OtherMiddleName: | MELISSA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3975 WILMINGTON AVE | ||||||||
| Address2: | APT A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631163250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142808157 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13515 BARRETT PARKWAY DR | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630215870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147752811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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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 | 163W00000X | 041.389801 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 086232 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2016017057 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.