Basic Information
| Provider Information | |||||||||
| NPI: | 1205187408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | RENEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1551 WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692268 | ||||||||
| FaxNumber: | 3142098127 | ||||||||
| Practice Location | |||||||||
| Address1: | 10135 W FLORISSANT AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631362103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145211444 | ||||||||
| FaxNumber: | 3145212299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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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 | 363LW0102X | 098909 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 098909 | 01 | MO | LICENSE | OTHER |