Provider Demographics
NPI:1073394367
Name:RUIZ, THALIA DALIZ
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:DALIZ
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18336 EDISON AVE # 1040
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-3618
Mailing Address - Country:US
Mailing Address - Phone:636-557-2825
Mailing Address - Fax:
Practice Address - Street 1:17050 SANDALWOOD CREEK DR APT A
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63038-1570
Practice Address - Country:US
Practice Address - Phone:636-557-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO172V00000X, 174N00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No174N00000XOther Service ProvidersLactation Consultant, Non-RN