=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992082325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN MARY CAFAZZA APRN, PNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2011
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 MEDICAL PLZ STE 200
-----------------------------------------------------
City | LAKE ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-625-2662
-----------------------------------------------------
Fax | 636-625-1186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 MEDICAL PLZ STE 200
-----------------------------------------------------
City | LAKE ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-591-1086
-----------------------------------------------------
Fax | 636-625-1186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 2011037407
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 2008023068
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------