Healthcare Provider Details

I. General information

NPI: 1437523677
Provider Name (Legal Business Name): KRISTA N LUDWIG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2015
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-6220
  • Fax:
Mailing address:
  • Phone: 618-257-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013618
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209013618
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: