Basic Information
| Provider Information | |||||||||
| NPI: | 1477952067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDECK | ||||||||
| FirstName: | BRIANA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 W LINCOLN ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777400 | ||||||||
| FaxNumber: | 6182777422 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184638610 | ||||||||
| FaxNumber: | 6184638688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2014 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209011703 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.