Healthcare Provider Details

I. General information

NPI: 1528653524
Provider Name (Legal Business Name): KATHLEEN ANNE OKUMU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 FLINTSHIRE LN
LAKE ST LOUIS MO
63367-1952
US

IV. Provider business mailing address

1210 FLINTSHIRE LN
LAKE ST LOUIS MO
63367-1952
US

V. Phone/Fax

Practice location:
  • Phone: 314-580-2313
  • Fax:
Mailing address:
  • Phone: 314-580-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2001001400
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: