Basic Information
| Provider Information | |||||||||
| NPI: | 1861796864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMES | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | LATRICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN,ANP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | USSERY | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | LATRICE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148385702 | ||||||||
| FaxNumber: | 3148395596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 GRAHAM RD | ||||||||
| Address2: | C-1330 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148385702 | ||||||||
| FaxNumber: | 3148395596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2011 | ||||||||
| LastUpdateDate: | 04/08/2013 | ||||||||
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| 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 | 363L00000X | 2011000076 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.