Healthcare Provider Details

I. General information

NPI: 1770723132
Provider Name (Legal Business Name): KATHERINE GRUENKEMEYER RN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

5321 BURGUNDY DR
IMPERIAL MO
63052-2096
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5351
  • Fax: 314-268-4151
Mailing address:
  • Phone: 314-577-5351
  • Fax: 314-268-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2005023014
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2005023014
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: