Provider Demographics
NPI:1457337222
Name:LOUGHREN, KATHY JO (NNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JO
Last Name:LOUGHREN
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:JO
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:3801 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4840
Mailing Address - Country:US
Mailing Address - Phone:314-332-2395
Mailing Address - Fax:
Practice Address - Street 1:3801 WYOMING ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4840
Practice Address - Country:US
Practice Address - Phone:314-332-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3305452363LN0000X, 363L00000X
MO085789363LN0000X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9326OtherBCBS
FL303542500Medicaid
Y9326OtherBCBS