Healthcare Provider Details

I. General information

NPI: 1457800542
Provider Name (Legal Business Name): SUZANNE KAELBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 COLEBROOK DR
SAINT LOUIS MO
63119-4114
US

IV. Provider business mailing address

602 COLEBROOK DR
SAINT LOUIS MO
63119-4114
US

V. Phone/Fax

Practice location:
  • Phone: 314-303-2081
  • Fax:
Mailing address:
  • Phone: 314-303-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2009017666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: