Provider Demographics
NPI:1902846694
Name:GOTTUSO, BRENDA S (ANP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:GOTTUSO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-831-0181
Mailing Address - Fax:314-851-4471
Practice Address - Street 1:2175 CHARBONIER RD
Practice Address - Street 2:SUITE B
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5500
Practice Address - Country:US
Practice Address - Phone:314-831-0181
Practice Address - Fax:314-851-4471
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO092325363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420126401Medicaid
MOS90768Medicare UPIN
MO420126401Medicaid
MO805105684Medicare PIN