Provider Demographics
NPI:1417589052
Name:FAJIC, SAMRA (ACNP)
Entity Type:Individual
Prefix:MS
First Name:SAMRA
Middle Name:
Last Name:FAJIC
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 N NEW BALLAS RD STE 240
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6819
Mailing Address - Country:US
Mailing Address - Phone:314-567-5100
Mailing Address - Fax:314-362-9878
Practice Address - Street 1:522 N NEW BALLAS RD STE 240
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6819
Practice Address - Country:US
Practice Address - Phone:314-567-5100
Practice Address - Fax:314-567-3387
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020004945363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420081760Medicaid