Individual
REBECCA DEATHERAGE BUWALDA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRNBC
Contact information
Practice address
12255 DE PAUL DR STE 600, BRIDGETON, MO 63044-2515
(314) 209-5100
(314) 291-9508
Mailing address
PO BOX 955534, SAINT LOUIS, MO 63195-2510
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
FNP 124462
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P21556
RAILROAD MEDICARE
MO
Enumeration date
07/11/2006
Last updated
10/20/2020
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