Provider Demographics
NPI:1063949659
Name:SANNI, CHRISTINA LOUISE
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:LOUISE
Last Name:SANNI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 105775
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-5775
Mailing Address - Country:US
Mailing Address - Phone:573-690-7919
Mailing Address - Fax:573-886-7771
Practice Address - Street 1:1026 NORTHEAST DR STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2517
Practice Address - Country:US
Practice Address - Phone:573-690-7919
Practice Address - Fax:573-636-7771
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017014822101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490042882Medicaid