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General NPI Number Information
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NPI Number | 1063015329
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Entity Type | Individual
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Provider Name | KIALY ANN MUDD FNP-C
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Gender | Female
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 4280 MID AMERICA LN STE 30
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City | SAINT LOUIS
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State | MO
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Zip | 63129-1202
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Country | US
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Telephone | 314-782-2600
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Fax |
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Provider Business Mailing Address
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Address Line | 326 SUMMER TOP LN
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City | FENTON
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State | MO
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Zip | 63026-3946
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Country | US
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Telephone | 314-809-8625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2020019127
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License Number State | MO
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