Provider Demographics
NPI:1679043665
Name:NIEDERSCHULTE, ELIZABETH ANNE (AGNP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:NIEDERSCHULTE
Suffix:
Gender:F
Credentials:AGNP
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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:314-362-1291
Mailing Address - Fax:314-996-3268
Practice Address - Street 1:1020 N MASON RD
Practice Address - Street 2:DIV IM CARDIOLOGY, STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6666
Practice Address - Country:US
Practice Address - Phone:314-362-1291
Practice Address - Fax:314-996-3268
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2024-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2018039908363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420079628Medicaid