Provider Demographics
NPI:1427388776
Name:MARTIN-BREDAHL, KATHERINE J (FNP)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:J
Last Name:MARTIN-BREDAHL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 N MASON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6338
Mailing Address - Country:US
Mailing Address - Phone:314-996-3434
Mailing Address - Fax:
Practice Address - Street 1:969 N MASON RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6338
Practice Address - Country:US
Practice Address - Phone:314-996-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-09
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023198363L00000X, 363LF0000X
MO2009037799363LF0000X, 363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1427388776Medicaid
ILENROLLEDMedicaid