Provider Demographics
NPI:1154104859
Name:WALLWEBER, MICHELLE LOUISE (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:WALLWEBER
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 STRAWGRASS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-2301
Mailing Address - Country:US
Mailing Address - Phone:314-495-8821
Mailing Address - Fax:
Practice Address - Street 1:21 MEADOWS CIRCLE DR STE 324
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4110
Practice Address - Country:US
Practice Address - Phone:636-389-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024001831363LF0000X
MO2002019911163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2024001831OtherSTATE OF MO CERTIFIED NURSE PRACTITIONER