Provider Demographics
NPI:1568698744
Name:GREGORY, KIM DENISE (ANP-BC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DENISE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:DENISE
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
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:314-645-3743
Mailing Address - Fax:314-647-7967
Practice Address - Street 1:1027 BELLEVUE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1851
Practice Address - Country:US
Practice Address - Phone:314-645-3743
Practice Address - Fax:314-647-7967
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO099537363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health