Healthcare Provider Details

I. General information

NPI: 1770048308
Provider Name (Legal Business Name): KELBY LYNN WITHROW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13861 MANCHESTER RD
BALLWIN MO
63011-4503
US

IV. Provider business mailing address

4603 MATTIS RD
SAINT LOUIS MO
63128-3015
US

V. Phone/Fax

Practice location:
  • Phone: 636-556-0114
  • Fax:
Mailing address:
  • Phone: 618-316-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2022009903
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: