Healthcare Provider Details

I. General information

NPI: 1376366765
Provider Name (Legal Business Name): HAWA CISSOKHO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17178 ELM TRAIL DR
EUREKA MO
63025-2344
US

IV. Provider business mailing address

1717 INDUSTRIAL DR
JEFFERSON CITY MO
65109-1468
US

V. Phone/Fax

Practice location:
  • Phone: 636-628-6785
  • Fax:
Mailing address:
  • Phone: 573-358-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2024088847
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: