Provider Demographics
NPI:1275599615
Name:MARSHALL, REDONDA (MSN, APRN, BC,FNP)
Entity Type:Individual
Prefix:
First Name:REDONDA
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MSN, APRN, BC,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-815-8130
Mailing Address - Fax:573-815-8149
Practice Address - Street 1:1605 E BROADWAY
Practice Address - Street 2:STE 110
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-8130
Practice Address - Fax:573-815-8149
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO102896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423962026Medicaid
MO423962026Medicaid