Healthcare Provider Details

I. General information

NPI: 1639531932
Provider Name (Legal Business Name): CIERRA WANDRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12348 OLD TESSON RD STE 160
SAINT LOUIS MO
63128
US

IV. Provider business mailing address

12348 OLD TESSON RD STE 160
SAINT LOUIS MO
63128-2251
US

V. Phone/Fax

Practice location:
  • Phone: 314-467-3800
  • Fax: 314-577-5616
Mailing address:
  • Phone: 314-467-3800
  • Fax: 314-577-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1639531932
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: