Healthcare Provider Details

I. General information

NPI: 1609931963
Provider Name (Legal Business Name): MARISSA LYNN SAENGSAMRAN APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 S KIRKWOOD RD STE 210
SAINT LOUIS MO
63122-6056
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-4500
  • Fax: 314-645-5907
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2001015646
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: