Healthcare Provider Details

I. General information

NPI: 1356585467
Provider Name (Legal Business Name): KRISTEN M LIEBIG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN M BALLANTINI

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-7222
  • Fax: 636-200-4036
Mailing address:
  • Phone: 636-386-7222
  • Fax: 636-200-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2005023468
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2005023468
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209028393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: