Basic Information
| Provider Information | |||||||||
| NPI: | 1760136634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUDERS | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | PAIGE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EADS | ||||||||
| OtherFirstName: | KATE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633034120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 1628 OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646832565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603594600 | ||||||||
| FaxNumber: | 6603594286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2016025596 | MO | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.