Provider Demographics
NPI:1851381206
Name:NEUDECKER, MICHELE
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:NEUDECKER
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 1:6651 CHIPPEWA ST STE 322
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2532
Mailing Address - Country:US
Mailing Address - Phone:314-457-9338
Mailing Address - Fax:314-457-9341
Practice Address - Street 1:2325 DOUGHERTY FERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:148-216-8893
Practice Address - Fax:314-457-9341
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076292363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS68977Medicare UPIN