Provider Demographics
NPI:1639531932
Name:WANDRO, CIERRA
Entity Type:Individual
Prefix:
First Name:CIERRA
Middle Name:
Last Name:WANDRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12348 OLD TESSON RD STE 160
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2251
Mailing Address - Country:US
Mailing Address - Phone:314-467-3800
Mailing Address - Fax:314-577-5616
Practice Address - Street 1:12348 OLD TESSON RD STE 160
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-467-3800
Practice Address - Fax:314-577-5616
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1639531932208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty