Provider Demographics
NPI:1881790996
Name:ACKLIN, YOLANDA A (NP)
Entity type:Individual
Prefix:
First Name:YOLANDA
Middle Name:A
Last Name:ACKLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COMANCHE LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6304
Mailing Address - Country:US
Mailing Address - Phone:314-838-4042
Mailing Address - Fax:
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8014
Practice Address - Country:US
Practice Address - Phone:314-953-6000
Practice Address - Fax:314-953-6001
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO058769363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427543400Medicaid
MO427543400Medicaid
MO828534740Medicare PIN
MO828534748Medicare PIN
MO828534748Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL PROVI
MO828534740Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL PROVI