Provider Demographics
NPI:1457861064
Name:FITCH, YOLANDA RENA
Entity Type:Individual
Prefix:MRS
First Name:YOLANDA
Middle Name:RENA
Last Name:FITCH
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 1:7369 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1722
Mailing Address - Country:US
Mailing Address - Phone:314-727-7257
Mailing Address - Fax:
Practice Address - Street 1:7369 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY CITY
Practice Address - State:MO
Practice Address - Zip Code:63130-1722
Practice Address - Country:US
Practice Address - Phone:314-727-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC9834414374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35-2587185Medicaid