Healthcare Provider Details

I. General information

NPI: 1902929896
Provider Name (Legal Business Name): KATONNA RICHARDSON RN, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1347 MCCAUSLAND AVE
SAINT LOUIS MO
63117-1945
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5631
  • Fax: 314-268-6474
Mailing address:
  • Phone: 314-646-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number069735
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: