Provider Demographics
NPI:1225586936
Name:DETCHEMENDY, ANITA (ANP)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:DETCHEMENDY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SAINT LUKES CENTER DR
Mailing Address - Street 2:SUITE 506
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3518
Mailing Address - Country:US
Mailing Address - Phone:314-576-8102
Mailing Address - Fax:314-590-5930
Practice Address - Street 1:121 SAINT LUKES CENTER DR
Practice Address - Street 2:SUITE 506
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3518
Practice Address - Country:US
Practice Address - Phone:314-576-8102
Practice Address - Fax:314-590-5930
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOAG0216198363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology