Basic Information
| Provider Information | |||||||||
| NPI: | 1619359486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDELOW WOOTTEN | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSN, APRN, FNP-C | ||||||||
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| OtherLastName: | MENDELOW | ||||||||
| OtherFirstName: | SARA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12680 OLIVE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12680 OLIVE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2015021537 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1619359486 | 05 | MO | MEDICAID | P01628637 | 01 | MO | RAILROAD MEDICARE | OTHER |