Provider Demographics
NPI:1861460180
Name:DETTENMEIER, PATRICIA ANN (MSN CS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:DETTENMEIER
Suffix:
Gender:F
Credentials:MSN CS
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:WITTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-4440
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-977-6190
Practice Address - Fax:314-268-5108
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO78947163WC0200X, 163WM0705X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health