1417531930 NPI number — MS. ASHLEY D VERSLUYS AGNP

Table of content: MS. ASHLEY D VERSLUYS AGNP (NPI 1417531930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417531930 NPI number — MS. ASHLEY D VERSLUYS AGNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERSLUYS
Provider First Name:
ASHLEY
Provider Middle Name:
D
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AGNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417531930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 S EUCLID AVE
Provider Second Line Business Mailing Address:
MSC 8234-05-02
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-362-7260
Provider Business Mailing Address Fax Number:
314-362-6288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 MEMORIAL DR
Provider Second Line Business Practice Location Address:
DIV SURG CT ADULT CARDIO, STE 100
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-5368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-362-7260
Provider Business Practice Location Address Fax Number:
314-747-4216
Provider Enumeration Date:
05/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  209023360 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420118894 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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