Provider Demographics
NPI:1174497721
Name:SUDDUTH, EBONY CASSANDRA
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:CASSANDRA
Last Name:SUDDUTH
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 1:10200 CEDARHURST DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-5616
Mailing Address - Country:US
Mailing Address - Phone:636-628-5801
Mailing Address - Fax:
Practice Address - Street 1:4801 WELDON SPRING PKWY
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-9101
Practice Address - Country:US
Practice Address - Phone:636-441-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025041043363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health