Provider Demographics
NPI:1215263397
Name:ELMORE, HEATHER NICOLE (ANP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:ELMORE
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 1:4920 AUTUMN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8504
Mailing Address - Country:US
Mailing Address - Phone:618-205-3251
Mailing Address - Fax:
Practice Address - Street 1:625 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2010
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8253
Practice Address - Country:US
Practice Address - Phone:314-251-3922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001028801363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health