Healthcare Provider Details

I. General information

NPI: 1376816157
Provider Name (Legal Business Name): KATHLEEN EASTWOOD CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD STE 2009B
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

615 S NEW BALLAS RD STE 2009B
SAINT LOUIS MO
63141-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6092
  • Fax:
Mailing address:
  • Phone: 314-251-6092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number121843
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: