Basic Information
| Provider Information | |||||||||
| NPI: | 1083933626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORMOL | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13515 BARRETT PARKWAY DR STE 170 | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630215870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147752816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1015 BOWLES AVE | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630262394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364962000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2010 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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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 | 207L00000X | 123598 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.