Healthcare Provider Details

I. General information

NPI: 1790431336
Provider Name (Legal Business Name): KRISTINE MARIE RUZICKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4251 FOREST PARK AVE
SAINT LOUIS MO
63108-2810
US

IV. Provider business mailing address

436 LEE AVE
KIRKWOOD MO
63122-5940
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-7526
  • Fax:
Mailing address:
  • Phone: 314-780-0246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number155188
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: