Healthcare Provider Details

I. General information

NPI: 1184560575
Provider Name (Legal Business Name): KATIE DIENELL PAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MERAMEC BOTTOM RD STE C
SAINT LOUIS MO
63129-2564
US

IV. Provider business mailing address

4401 MERAMEC BOTTOM RD STE C
SAINT LOUIS MO
63129-2564
US

V. Phone/Fax

Practice location:
  • Phone: 314-583-9551
  • Fax: 636-791-0306
Mailing address:
  • Phone:
  • Fax: 636-791-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIE TUHILL
Title or Position: OWNER PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 314-583-9551