Provider Demographics
NPI:1558538850
Name:WAKEFIELD, PATRICE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:LYNN
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 DONNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3918
Mailing Address - Country:US
Mailing Address - Phone:314-721-7329
Mailing Address - Fax:314-725-2319
Practice Address - Street 1:514 DONNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-3918
Practice Address - Country:US
Practice Address - Phone:314-721-7329
Practice Address - Fax:314-725-2319
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34692208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice