Provider Demographics
NPI:1407363716
Name:LANDRY, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 OLYVIA DR
Practice Address - Street 2:
Practice Address - City:SAINT JACOB
Practice Address - State:IL
Practice Address - Zip Code:62281-1567
Practice Address - Country:US
Practice Address - Phone:618-520-7204
Practice Address - Fax:618-520-7204
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008023105163W00000X, 163WC0200X
IL041425794163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse