Provider Demographics
NPI:1104225648
Name:CHIPEPO, MWEEMBA (ANP)
Entity type:Individual
Prefix:
First Name:MWEEMBA
Middle Name:
Last Name:CHIPEPO
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 N BALLAS RD STE 383C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2324
Mailing Address - Country:US
Mailing Address - Phone:314-996-4545
Mailing Address - Fax:314-996-4546
Practice Address - Street 1:3009 N BALLAS RD STE 383C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-996-4545
Practice Address - Fax:314-996-4546
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006304363LA2200X
MO2014020747363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health