Healthcare Provider Details

I. General information

NPI: 1699679282
Provider Name (Legal Business Name): CHEYENNE L. MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

4401 VISTA AVE
SAINT LOUIS MO
63110-2135
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6000
  • Fax:
Mailing address:
  • Phone: 561-635-9231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: