Provider Demographics
NPI:1477952067
Name:WALDECK, BRIANA (NP)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:WALDECK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:618-277-7422
Practice Address - Street 1:5520 GODFREY RD STE B
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2741
Practice Address - Country:US
Practice Address - Phone:618-463-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011703363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily