Healthcare Provider Details

I. General information

NPI: 1780884916
Provider Name (Legal Business Name): KATHLEEN ANN WOODS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-7010
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1999136138
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR878465
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: