Healthcare Provider Details

I. General information

NPI: 1255088191
Provider Name (Legal Business Name): ELENA KOZARYUK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11716 STUDT AVE
SAINT LOUIS MO
63141-7018
US

IV. Provider business mailing address

11716 STUDT AVE
SAINT LOUIS MO
63141-7018
US

V. Phone/Fax

Practice location:
  • Phone: 314-330-8117
  • Fax:
Mailing address:
  • Phone: 314-330-8117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2020037156
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: