Provider Demographics
NPI:1760136634
Name:SOUDERS, KATELYN PAIGE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:PAIGE
Last Name:SOUDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:EADS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1628 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2565
Practice Address - Country:US
Practice Address - Phone:660-359-4600
Practice Address - Fax:660-359-4286
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016025596164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse