Provider Demographics
NPI:1033840228
Name:PONTICELLO, PAIGE NICOLE (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:NICOLE
Last Name:PONTICELLO
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22819 PAUL RD
Mailing Address - Street 2:
Mailing Address - City:MARTHASVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63357-2550
Mailing Address - Country:US
Mailing Address - Phone:314-809-4123
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 560A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8261
Practice Address - Country:US
Practice Address - Phone:314-251-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022022670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily