Basic Information
| Provider Information | |||||||||
| NPI: | 1669430575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERFORD | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ALEXA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 EAST HIGHWAY 60 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655487381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4179342251 | ||||||||
| FaxNumber: | 4179342871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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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 | 363LF0000X | 129188 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 428643639 | 05 | MO | MEDICAID | 1669430575 | 05 | MO | MEDICAID | P00852026 | 01 | MO | PALMETTO GBA/RR MEDICARE | OTHER |