Provider Demographics
NPI:1972787398
Name:DIVAKARAN, VIJAYALAKSHMI (ARNP, BC)
Entity type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:DIVAKARAN
Suffix:
Gender:F
Credentials:ARNP, BC
Other - Prefix:
Other - First Name:VIJAYALAKSHMI
Other - Middle Name:
Other - Last Name:VELLAICHAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP, BC
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8666
Mailing Address - Country:US
Mailing Address - Phone:314-880-6100
Mailing Address - Fax:314-997-3248
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-842-0602
Practice Address - Fax:314-842-4372
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002031628363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424053700Medicaid
MO836972006Medicare PIN
MO424053700Medicaid