Provider Demographics
NPI:1639644552
Name:LOVE, TRALISSA S (AGNP)
Entity Type:Individual
Prefix:MS
First Name:TRALISSA
Middle Name:S
Last Name:LOVE
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-362-0338
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:DIV NEURO GENERAL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-362-0338
Is Sole Proprietor?:No
Enumeration Date:2018-10-07
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2018003390363LA2200X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420101737Medicaid