Provider Demographics
NPI:1174150726
Name:WINE, KATY HELENE (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:HELENE
Last Name:WINE
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:1414 CROSS ST STE 240
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2941
Practice Address - Country:US
Practice Address - Phone:618-234-2390
Practice Address - Fax:618-234-9936
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2019001390363L00000X, 363LF0000X
IL209018627363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily