Healthcare Provider Details

I. General information

NPI: 1083527410
Provider Name (Legal Business Name): LAURA KATHLEEN LIST RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

19 SCARLET CT
SAINT CHARLES MO
63304-6775
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6000
  • Fax:
Mailing address:
  • Phone: 636-896-6645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2026047004
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: