=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710686894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA RENEE KOOTMAN MSN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2023
-----------------------------------------------------
Last Update Date | 07/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 S NEW BALLAS RD STE 5003B
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-8270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-251-8892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 927 MOREHOUSE LN
-----------------------------------------------------
City | UNIVERSITY CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63130-2157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-341-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2023005440
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------