Healthcare Provider Details

I. General information

NPI: 1003567215
Provider Name (Legal Business Name): KIERRA K CALICO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-6071
  • Fax: 314-453-9965
Mailing address:
  • Phone: 314-567-6071
  • Fax: 314-453-9965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028348
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-80842-052
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022000769
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: