Healthcare Provider Details

I. General information

NPI: 1871969105
Provider Name (Legal Business Name): SANDRA AVITIA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHOUTEAU AVE
SAINT LOUIS MO
63103-2910
US

IV. Provider business mailing address

31 PEARTREE LN
GLEN CARBON IL
62034-4312
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-1250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015026485
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013047
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209013047
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: