Healthcare Provider Details

I. General information

NPI: 1144425083
Provider Name (Legal Business Name): KAYLEA MARIE BOUTWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 N OUTER 40 RD SUITE 360
CHESTERFIELD MO
63017-2152
US

IV. Provider business mailing address

14825 N OUTER 40 RD SUITE 360
CHESTERFIELD MO
63017-2152
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-2570
  • Fax: 314-336-2571
Mailing address:
  • Phone: 314-336-2570
  • Fax: 314-336-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2009025407
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number2009025407
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: