Healthcare Provider Details

I. General information

NPI: 1588480842
Provider Name (Legal Business Name): KILANNIN CATHLEEN KRYSIAK PHD, FACMG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FOREST PARK AVE
SAINT LOUIS MO
63108-2979
US

IV. Provider business mailing address

660 S EUCLID AVE # 81189902
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-4218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: