Provider Demographics
NPI:1306097464
Name:ANDERSEN, KATHLEEN ELIZABETH (KATHLEEN KNEBELSBERG)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:KATHLEEN KNEBELSBERG
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:KNEBELSBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:512-586-9223
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:512-586-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008030514367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant