Healthcare Provider Details

I. General information

NPI: 1336629641
Provider Name (Legal Business Name): CATHERINE DOLPHIN SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD STE 120B
BALLWIN MO
63011-2490
US

IV. Provider business mailing address

15945 CLAYTON RD STE 120B
BALLWIN MO
63011-2490
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-5070
  • Fax: 636-256-5066
Mailing address:
  • Phone: 636-256-5070
  • Fax: 696-256-5066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2018024092
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2018024092
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: