Healthcare Provider Details

I. General information

NPI: 1194314534
Provider Name (Legal Business Name): KATHLEEN ELIZABETH GRUSZKA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN ELIZABETH MCMAHON RN

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 CLAYTON RD
CLAYTON MO
63117-1103
US

IV. Provider business mailing address

600 WHISKEY SPRINGS RD
BOILING SPRINGS PA
17007-9519
US

V. Phone/Fax

Practice location:
  • Phone: 314-726-2124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041488461
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2019019049
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN676565
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: