Provider Demographics
NPI:1114540978
Name:VISONNAVONG, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:VISONNAVONG
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 1:226 S WOODS MILL RD STE 35
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3662
Mailing Address - Country:US
Mailing Address - Phone:314-548-6860
Mailing Address - Fax:314-548-6866
Practice Address - Street 1:226 S WOODS MILL RD STE 35
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-548-6860
Practice Address - Fax:314-548-6866
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019039787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant