Provider Demographics
NPI:1316446461
Name:NETTLES, DENISE L
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:L
Last Name:NETTLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7229 PASADENA BLVD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:UNITED STATE
Mailing Address - Zip Code:63121
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7229 PASADENA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-2914
Practice Address - Country:US
Practice Address - Phone:314-281-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO824255694Medicaid