Provider Demographics
NPI:1366853541
Name:CALVIN, GINA R (FNP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:R
Last Name:CALVIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:R
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1111 W PEARCE BLVD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-1020
Mailing Address - Country:US
Mailing Address - Phone:636-856-5362
Mailing Address - Fax:
Practice Address - Street 1:1111 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1020
Practice Address - Country:US
Practice Address - Phone:636-856-5362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20113044837363LF0000X
MO2013044837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1366853541Medicaid