Provider Demographics
NPI:1881946358
Name:TELLINI, SUSAN M (NP-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:TELLINI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:STOCKGLAUSNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:15838 FOUNTAIN PLAZA DR STE A
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7469
Mailing Address - Country:US
Mailing Address - Phone:636-484-5277
Mailing Address - Fax:
Practice Address - Street 1:15838 FOUNTAIN PLAZA DR STE A
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7469
Practice Address - Country:US
Practice Address - Phone:636-484-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2012027797OtherMO STATE BOARD OF NURSING
MO2012027797OtherMO STATE BOARD OF NURSING
MO152800120Medicare PIN