Healthcare Provider Details

I. General information

NPI: 1518320662
Provider Name (Legal Business Name): KAITLYN KENNARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 10/07/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV SURG ONCOLOGY, STE 5F
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8109-0037-09
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-2280
  • Fax: 888-352-8360
Mailing address:
  • Phone: 314-362-2280
  • Fax: 888-352-8360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2022029282
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: