Provider Demographics
NPI:1851728216
Name:WELBY, DESIRAE RENEE (APN)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:RENEE
Last Name:WELBY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD STE 260
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3288
Mailing Address - Country:US
Mailing Address - Phone:314-543-5270
Mailing Address - Fax:
Practice Address - Street 1:12700 SOUTHFORK RD STE 260
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3288
Practice Address - Country:US
Practice Address - Phone:314-543-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012412363L00000X
MO2013036176363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner