Provider Demographics
NPI:1942508783
Name:MOULDON, ANDREA L (PNP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:L
Last Name:MOULDON
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Gender:F
Credentials:PNP
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Mailing Address - Street 1:3737 N KINGSHIGHWAY BLVD
Mailing Address - Street 2:STE 209
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-1736
Mailing Address - Country:US
Mailing Address - Phone:314-261-5250
Mailing Address - Fax:314-261-4567
Practice Address - Street 1:3737 N KINGSHIGHWAY BLVD
Practice Address - Street 2:STE 209
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1736
Practice Address - Country:US
Practice Address - Phone:314-261-5250
Practice Address - Fax:314-261-4567
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2021-11-29
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Provider Licenses
StateLicense IDTaxonomies
MO2010016423363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429600703Medicaid