Provider Demographics
NPI:1942759493
Name:WHITESIDES, MELANIE EILEEN (CAA)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:EILEEN
Last Name:WHITESIDES
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:EILEEN
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-386-7679
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:636-386-9224
Practice Address - Fax:636-386-7679
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034131367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant