Healthcare Provider Details

I. General information

NPI: 1083429526
Provider Name (Legal Business Name): SAMANTHA CHRISTINE KIZER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

4805 STOREYLAND DR
ALTON IL
62002-5834
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6082
  • Fax:
Mailing address:
  • Phone: 618-419-3727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025003957
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2025003957
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: