Provider Demographics
NPI:1447552260
Name:WATERBURY, JULIE LYNNE (APRN-FNP)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:LYNNE
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:APRN-FNP
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10420 OLD OLIVE STREET RD STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5937
Mailing Address - Country:US
Mailing Address - Phone:314-504-4698
Mailing Address - Fax:314-692-9978
Practice Address - Street 1:10420 OLD OLIVE STREET RD STE 205
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5937
Practice Address - Country:US
Practice Address - Phone:314-504-4698
Practice Address - Fax:314-692-9978
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011023150363L00000X, 363LP0808X
NVAPN001241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV35664OtherMEDICARE GROUP PTAN
NV000010742-00OtherOHIO W/COMP ID
AZZ35713OtherMEDICARE GROUP PTAN
NVV35664OtherMEDICARE GROUP PTAN
NVEN880YMedicare PIN