Provider Demographics
NPI:1790431336
Name:RUZICKA, KRISTINE MARIE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:RUZICKA
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 1:436 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5940
Mailing Address - Country:US
Mailing Address - Phone:314-780-0246
Mailing Address - Fax:
Practice Address - Street 1:4251 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:314-531-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO155188176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife