Healthcare Provider Details

I. General information

NPI: 1396125159
Provider Name (Legal Business Name): SARA PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 LINDELL BLVD FL 2
SAINT LOUIS MO
63108-3739
US

IV. Provider business mailing address

16240 FOSTER ST
STILWELL KS
66085-8418
US

V. Phone/Fax

Practice location:
  • Phone: 914-919-9200
  • Fax:
Mailing address:
  • Phone: 913-894-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number76822
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: