Basic Information
| Provider Information | |||||||||
| NPI: | 1881289262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | NOLAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3449 MACKLIND AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631391562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017655288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143735740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2021 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2021023487 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.