Healthcare Provider Details

I. General information

NPI: 1922262377
Provider Name (Legal Business Name): ELIZABETH ANN HERMANN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN KLOTZ P.A.

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

11475 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4492
  • Fax: 314-525-4481
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2008020159
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: