Healthcare Provider Details

I. General information

NPI: 1639892755
Provider Name (Legal Business Name): KATELYN DEADERICK APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-1765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9581797
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11024131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: