Healthcare Provider Details

I. General information

NPI: 1740714724
Provider Name (Legal Business Name): CATHERINE KAGOTHO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 BELLEVUE AVE
SAINT LOUIS MO
63117-1996
US

IV. Provider business mailing address

1027 BELLEVUE AVE
SAINT LOUIS MO
63117-1996
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-5202
  • Fax:
Mailing address:
  • Phone: 314-768-5202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015440
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016031428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: