Provider Demographics
NPI:1407417645
Name:DERDERIAN, KRISTEN ALICE (CNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ALICE
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12200 WEBER HILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1599
Mailing Address - Country:US
Mailing Address - Phone:314-698-2500
Mailing Address - Fax:508-823-5689
Practice Address - Street 1:12200 WEBER HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1599
Practice Address - Country:US
Practice Address - Phone:314-698-2500
Practice Address - Fax:314-698-2323
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2321686363LP2300X
MO2021013574363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care