Provider Demographics
NPI:1366997306
Name:POLLOCK, SAMANTHA WATANAPONGSE (APRN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:WATANAPONGSE
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12125 WOODCREST EXECUTIVE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12125 WOODCREST EXECUTIVE DR STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5009
Practice Address - Country:US
Practice Address - Phone:314-789-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0121921363LG0600X
MO2020038833363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology