Healthcare Provider Details

I. General information

NPI: 1972734523
Provider Name (Legal Business Name): JAIME LYNN KYNION FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAIME LYNN WICKERS

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1000
  • Fax:
Mailing address:
  • Phone: 314-525-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2006001300
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: