Healthcare Provider Details

I. General information

NPI: 1619895372
Provider Name (Legal Business Name): MICHAEL GERARD RUTTEN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8350 STATE ROUTE 30 # 63023
DITTMER MO
63023-1909
US

IV. Provider business mailing address

5633 WELMERING DR # 63123
SAINT LOUIS MO
63123-3659
US

V. Phone/Fax

Practice location:
  • Phone: 636-944-4400
  • Fax:
Mailing address:
  • Phone: 314-440-6223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2009004419
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: