Provider Demographics
NPI:1619359486
Name:WOOTTEN, SARA MENDELOW (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:MENDELOW
Last Name:WOOTTEN
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:MENDELOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 S NEW BALLAS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8725
Mailing Address - Country:US
Mailing Address - Phone:314-251-5890
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8725
Practice Address - Country:US
Practice Address - Phone:314-251-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619359486Medicaid
MOP01628637OtherRAILROAD MEDICARE
MO152800269Medicare PIN