Provider Demographics
NPI:1073501102
Name:FISHER, KATHLEEN L (RN, BC, ANP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:FISHER
Suffix:
Gender:F
Credentials:RN, BC, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 KENNERLY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-525-1220
Mailing Address - Fax:314-842-9952
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-525-1220
Practice Address - Fax:314-842-9952
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO086013363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427628102Medicaid
MO000081407Medicare ID - Type Unspecified
MO427628102Medicaid