Provider Demographics
NPI:1073025763
Name:STATON, CYRETHA ANN
Entity Type:Individual
Prefix:
First Name:CYRETHA
Middle Name:ANN
Last Name:STATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 ARMITAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6105
Mailing Address - Country:US
Mailing Address - Phone:314-862-0939
Mailing Address - Fax:314-355-0024
Practice Address - Street 1:2110 ARMITAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6105
Practice Address - Country:US
Practice Address - Phone:314-862-0939
Practice Address - Fax:314-355-0024
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003016442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist