Provider Demographics
NPI:1720474687
Name:ROY, CASANDRA ELAINE (NP)
Entity Type:Individual
Prefix:
First Name:CASANDRA
Middle Name:ELAINE
Last Name:ROY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CASANDRA
Other - Middle Name:ELAINE
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:P.O. BOX 23917
Mailing Address - Street 2:5731 MOUNT PLEASANT LN
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-0917
Mailing Address - Country:US
Mailing Address - Phone:618-401-9304
Mailing Address - Fax:586-204-0381
Practice Address - Street 1:16 PEBBLE HILL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-2250
Practice Address - Country:US
Practice Address - Phone:618-401-9304
Practice Address - Fax:586-204-0381
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015009441363LF0000X
IL209012471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1720474687Medicaid