Basic Information
| Provider Information | |||||||||
| NPI: | 1083233274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | GINA | ||||||||
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| OtherLastName: | AVELLONE | ||||||||
| OtherFirstName: | GINA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4707 VERGUENE AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631193305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144530990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 2019039994 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.