Healthcare Provider Details

I. General information

NPI: 1033861570
Provider Name (Legal Business Name): KATELYN A RYDER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 N GRAND BLVD
SAINT LOUIS MO
63103-2005
US

IV. Provider business mailing address

2814 OLD HIGHWAY A
FESTUS MO
63028-4737
US

V. Phone/Fax

Practice location:
  • Phone: 314-707-4496
  • Fax:
Mailing address:
  • Phone: 314-707-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2018009253
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: