Provider Demographics
NPI:1306214697
Name:MENTZ, KELSIE MARIE (ACNP)
Entity Type:Individual
Prefix:MS
First Name:KELSIE
Middle Name:MARIE
Last Name:MENTZ
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7603
Mailing Address - Fax:314-362-5470
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM NEPHROLOGY, STE 5C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7603
Practice Address - Fax:314-362-5470
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016001344363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420028400Medicaid