Healthcare Provider Details

I. General information

NPI: 1871657981
Provider Name (Legal Business Name): KRISTIN JOY WALD RNC, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 405
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 405
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-6986
  • Fax: 314-543-6836
Mailing address:
  • Phone: 314-543-6986
  • Fax: 314-543-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number147829
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: