Provider Demographics
NPI:1285912832
Name:LA SALLE, MELINDA JO WOLTERS (MSN, ACNP-BC)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:JO WOLTERS
Last Name:LA SALLE
Suffix:
Gender:F
Credentials:MSN, ACNP-BC
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:JO
Other - Last Name:CRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 FOREST PARK AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2885
Mailing Address - Country:US
Mailing Address - Phone:314-709-8322
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031271163W00000X
MO2011015338363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner