Provider Demographics
NPI:1346904646
Name:SUNTRUP, MIKKAELA (PTA)
Entity Type:Individual
Prefix:
First Name:MIKKAELA
Middle Name:
Last Name:SUNTRUP
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 MARDEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1551
Mailing Address - Country:US
Mailing Address - Phone:314-540-6440
Mailing Address - Fax:
Practice Address - Street 1:3501 DUNN RD STE 108
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6762
Practice Address - Country:US
Practice Address - Phone:314-972-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-24
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016025193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant