Provider Demographics
NPI:1891092474
Name:SCHNEIDER, KIMBERLY M (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:SCHNEIDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1836 LACKLAND HILL PARKWAY
Mailing Address - Street 2:ATTN CREDENTIALING DEPT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-872-1308
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:20B PROFESSIONAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-1480
Practice Address - Fax:618-288-2407
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085003987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant