Healthcare Provider Details

I. General information

NPI: 1306086582
Provider Name (Legal Business Name): CATHY WARE KOETTING CPNP, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 S LINDBERGH BLVD
SAINT LOUIS MO
63127-1832
US

IV. Provider business mailing address

3221 MCKELVEY RD STE 301
BRIDGETON MO
63044-2551
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-7669
  • Fax: 314-849-7670
Mailing address:
  • Phone: 636-498-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123616
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number123616
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number123616
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: