Healthcare Provider Details

I. General information

NPI: 1508359043
Provider Name (Legal Business Name): KATIE STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2018
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WEBER HILL RD STE 100
SAINT LOUIS MO
63127-1569
US

IV. Provider business mailing address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-698-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018029917
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009005945
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: