Provider Demographics
NPI:1275203721
Name:PIYAJESSADAKUL, SUTIRA (PNP)
Entity Type:Individual
Prefix:MS
First Name:SUTIRA
Middle Name:
Last Name:PIYAJESSADAKUL
Suffix:
Gender:F
Credentials:PNP
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:314-454-6300
Mailing Address - Fax:833-969-0131
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED ACADEMICS, STE 2D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6300
Practice Address - Fax:833-969-0131
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021017407363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420101821Medicaid