Healthcare Provider Details

I. General information

NPI: 1184528317
Provider Name (Legal Business Name): SARAH GRAVETTE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE SAINT LOUIS MO
63367-1366
US

IV. Provider business mailing address

100 MEDICAL PLZ
LAKE SAINT LOUIS MO
63367-1366
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-5424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2024024428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: