Provider Demographics
NPI:1235957275
Name:WASSON, KELLIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WASSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:ANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 CITYPLACE DR FL 2
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7390
Mailing Address - Country:US
Mailing Address - Phone:314-914-2717
Mailing Address - Fax:
Practice Address - Street 1:2 CITYPLACE DR FL 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7390
Practice Address - Country:US
Practice Address - Phone:314-914-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024069221363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420150983Medicaid