Provider Demographics
NPI:1871842534
Name:MIESNER, JENELLE ELIZABETH NADEAU (AA)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:ELIZABETH NADEAU
Last Name:MIESNER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:ELIZABETH
Other - Last Name:NADEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 22407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0407
Mailing Address - Country:US
Mailing Address - Phone:636-386-7222
Mailing Address - Fax:636-200-4036
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:636-200-4036
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012031791367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant