Provider Demographics
NPI:1114381563
Name:SHAUGHNESSY, KATHLEEN B (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-965-5437
Mailing Address - Fax:314-965-5439
Practice Address - Street 1:9580 WATSON RD
Practice Address - Street 2:STE A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1539
Practice Address - Country:US
Practice Address - Phone:314-965-5437
Practice Address - Fax:314-965-5439
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015037591363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics