Provider Demographics
NPI:1679228803
Name:SIDA, KATHLEEN JEANETTE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JEANETTE
Last Name:SIDA
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 1:8233 FENDALE DR
Mailing Address - Street 2:
Mailing Address - City:AFFTON
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3303
Mailing Address - Country:US
Mailing Address - Phone:314-315-0750
Mailing Address - Fax:
Practice Address - Street 1:637 DUNN RD STE 102A
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-831-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF01221105363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care