Individual
MRS. KELLY DOUGHERTY WASSEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PNP
Contact information
Practice address
12360 MANCHESTER RD, STE 100, SAINT LOUIS, MO 63131-4302
(314) 966-8500
(314) 996-4499
Mailing address
12360 MANCHESTER RD, STE 100, SAINT LOUIS, MO 63131-4302
(314) 966-8500
(314) 996-4499
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
2012006258
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
420020002
—
MO
Enumeration date
03/20/2012
Last updated
06/13/2019
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