Provider Demographics
NPI:1003323288
Name:WALDEN- PRATER, ELIZABETH BURTON (AGNP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:BURTON
Last Name:WALDEN- PRATER
Suffix:
Gender:F
Credentials:AGNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:MSC 8121-0022-07
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-5060
Mailing Address - Fax:314-996-3238
Practice Address - Street 1:1044 N MASON RD
Practice Address - Street 2:DIV IM GENERAL MED, STE 330
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6431
Practice Address - Country:US
Practice Address - Phone:314-996-8103
Practice Address - Fax:314-996-3230
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2023-09-26
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Provider Licenses
StateLicense IDTaxonomies
MO2018004474363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420051251Medicaid