Healthcare Provider Details

I. General information

NPI: 1740611649
Provider Name (Legal Business Name): PETRA KNIGHT MS, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7508 BIG BEND BLVD
ST. LOUIS MO
63119
US

IV. Provider business mailing address

7508 BIG BEND BLVD
ST. LOUIS MO
63119
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-1964
  • Fax:
Mailing address:
  • Phone: 314-647-1964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2013028784
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: