Provider Demographics
NPI:1356117568
Name:WALTSGOTT, KAITLYN MICHELLE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MICHELLE
Last Name:WALTSGOTT
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 1:867 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:AVISTON
Mailing Address - State:IL
Mailing Address - Zip Code:62216-3459
Mailing Address - Country:US
Mailing Address - Phone:618-616-7202
Mailing Address - Fax:
Practice Address - Street 1:7437 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4415
Practice Address - Country:US
Practice Address - Phone:314-687-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023046729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist