Healthcare Provider Details

I. General information

NPI: 1265397665
Provider Name (Legal Business Name): KELLEY MARIE LOVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 ENTRANCE WAY STE 100
SAINT PETERS MO
63376-1645
US

IV. Provider business mailing address

4921 PARKVIEW PL
SAINT LOUIS MO
63110-1032
US

V. Phone/Fax

Practice location:
  • Phone: 636-916-9920
  • Fax: 314-820-6699
Mailing address:
  • Phone: 314-747-8732
  • Fax: 314-820-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2025052824
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: