Healthcare Provider Details

I. General information

NPI: 1124601463
Provider Name (Legal Business Name): KATHRYN RUDY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax: 314-353-1310
Mailing address:
  • Phone: 314-353-5190
  • Fax: 314-353-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021641
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018039485
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: