Healthcare Provider Details

I. General information

NPI: 1922714575
Provider Name (Legal Business Name): STELLA KULKIN HEINE AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4440
  • Fax:
Mailing address:
  • Phone: 314-977-5060
  • Fax: 314-977-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2022046449
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: