Basic Information
| Provider Information | |||||||||
| NPI: | 1780884916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Practice Location | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R878465 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 1999136138 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 04950007 | 05 | MS | MEDICAID | 431560263 | 01 | TRICARE WEST | OTHER | 1780884916 | 05 | MO | MEDICAID |