Provider Demographics
NPI:1588102099
Name:ELIAS, JACQUELINE MEDINTZ (FNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MEDINTZ
Last Name:ELIAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:FANNIE
Other - Last Name:MEDINTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
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:
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:63131-2324
Practice Address - Country:US
Practice Address - Phone:314-996-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019103363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily