Basic Information
| Provider Information | |||||||||
| NPI: | 1235380064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETMER | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANE | ||||||||
| OtherFirstName: | STACIE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | F.N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
| FaxNumber: | 3148514445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 BOWLES AVE STE 450 | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630260562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144671500 | ||||||||
| FaxNumber: | 3144671515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2005018747 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.