Provider Demographics
NPI:1083081830
Name:MUJKANOVIC, ADELLA (ANP)
Entity Type:Individual
Prefix:MS
First Name:ADELLA
Middle Name:
Last Name:MUJKANOVIC
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7216
Mailing Address - Fax:314-362-8813
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM HEMATOLOGY, STE 7B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7216
Practice Address - Fax:314-362-8813
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015009963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420025592Medicaid