Provider Demographics
NPI:1417440835
Name:ROEDIGER, KELLEY (AGNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:
Last Name:ROEDIGER
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 DEERGRASS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4629
Mailing Address - Country:US
Mailing Address - Phone:314-814-1881
Mailing Address - Fax:
Practice Address - Street 1:232 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3406
Practice Address - Country:US
Practice Address - Phone:214-434-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOAG06180006363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health