Healthcare Provider Details

I. General information

NPI: 1538698733
Provider Name (Legal Business Name): KIMBERLY ANNE GARAVAGLIA CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9417 S BROADWAY
SAINT LOUIS MO
63125-2009
US

IV. Provider business mailing address

5501 DELMAR BLVD STE B560
SAINT LOUIS MO
63112-3084
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-4030
  • Fax: 314-833-4031
Mailing address:
  • Phone: 314-833-4030
  • Fax: 314-833-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2017006434
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: