Healthcare Provider Details

I. General information

NPI: 1114381563
Provider Name (Legal Business Name): KATHLEEN B SHAUGHNESSY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9580 WATSON RD STE A
SAINT LOUIS MO
63126-1539
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-5437
  • Fax: 314-965-5439
Mailing address:
  • Phone: 314-965-5437
  • Fax: 314-965-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2015037591
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: