Healthcare Provider Details

I. General information

NPI: 1902589062
Provider Name (Legal Business Name): AFSANEH REZAEIZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 CRAIGSHIRE DR STE 410
SAINT LOUIS MO
63146-4012
US

IV. Provider business mailing address

2055 CRAIGSHIRE DR
SAINT LOUIS MO
63146-4036
US

V. Phone/Fax

Practice location:
  • Phone: 314-228-3633
  • Fax: 314-949-8843
Mailing address:
  • Phone: 314-228-3633
  • Fax: 314-949-8843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1129729
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025053306
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: