Provider Demographics
NPI:1003362021
Name:NELLESEN, STEPHANIE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:NELLESEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 189A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8255
Mailing Address - Country:US
Mailing Address - Phone:314-251-6335
Mailing Address - Fax:314-251-5864
Practice Address - Street 1:621 S NEW BALLAS RD STE 189A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8255
Practice Address - Country:US
Practice Address - Phone:314-251-6335
Practice Address - Fax:314-251-5864
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016022548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily