Provider Demographics
NPI:1053911297
Name:DISTLER, MADELINE JANE (AGACNP)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:JANE
Last Name:DISTLER
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 CHILDRENS PL STOP 90-29916
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1020
Mailing Address - Country:US
Mailing Address - Phone:314-273-3194
Mailing Address - Fax:
Practice Address - Street 1:4590 CHILDRENS PL STOP 90-29916
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1020
Practice Address - Country:US
Practice Address - Phone:314-273-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020012267363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine