Healthcare Provider Details

I. General information

NPI: 1194472928
Provider Name (Legal Business Name): KELLY VOGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

13000 BUTLER CREST DR
SAINT LOUIS MO
63128-4276
US

V. Phone/Fax

Practice location:
  • Phone: 618-973-3468
  • Fax:
Mailing address:
  • Phone: 143-858-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2022007465
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: