Provider Demographics
NPI:1609931963
Name:SAENGSAMRAN, MARISSA LYNN (APRN, BC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:SAENGSAMRAN
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:816 S KIRKWOOD RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6056
Practice Address - Country:US
Practice Address - Phone:314-645-4500
Practice Address - Fax:314-645-5907
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001015646363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428314405Medicaid
MOQ17881Medicare UPIN
MO428314405Medicaid