Provider Demographics
NPI:1437512688
Name:BUSH, CATHLEEN
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:
Last Name:BUSH
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 1:5057 LAKEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:AFFTON
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3717
Mailing Address - Country:US
Mailing Address - Phone:314-457-0610
Mailing Address - Fax:
Practice Address - Street 1:5057 LAKEWOOD AVE
Practice Address - Street 2:
Practice Address - City:AFFTON
Practice Address - State:MO
Practice Address - Zip Code:63123-3717
Practice Address - Country:US
Practice Address - Phone:314-457-0610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO811707188376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO811707188OtherEIN