Healthcare Provider Details

I. General information

NPI: 1235210162
Provider Name (Legal Business Name): KATHLEEN MILES NIKODYM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 1ST CAPITOL DR STE 100
SAINT CHARLES MO
63301-2881
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-332-8455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2002004796
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2002004796
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: