Provider Demographics
NPI:1740475334
Name:THANAVARO, JOANNE L (ANP)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:L
Last Name:THANAVARO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2102
Mailing Address - Country:US
Mailing Address - Phone:314-534-8600
Mailing Address - Fax:314-652-8138
Practice Address - Street 1:114 N TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2102
Practice Address - Country:US
Practice Address - Phone:314-534-8600
Practice Address - Fax:314-652-8138
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO068133363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740475334Medicaid