Healthcare Provider Details

I. General information

NPI: 1043413842
Provider Name (Legal Business Name): KRISTEN M MENNEMEIER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN M ANDERSEN M.D.

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N. BALLAS RD. SUITE 257C
ST. LOUIS MO
63131-2308
US

IV. Provider business mailing address

3009 N. BALLAS RD. SUITE 257C
ST. LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-2112
  • Fax: 314-569-1270
Mailing address:
  • Phone: 314-569-2112
  • Fax: 314-569-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006015655
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2008029936
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: