Provider Demographics
NPI:1205474483
Name:LANTZ, KATIE R (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:R
Last Name:LANTZ
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ELLIS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1136
Mailing Address - Country:US
Mailing Address - Phone:217-649-8547
Mailing Address - Fax:
Practice Address - Street 1:1008 S SPRING AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2520
Practice Address - Country:US
Practice Address - Phone:314-977-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019043938363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care