Provider Demographics
NPI:1750737060
Name:COSBY, KAITLYN RAE (DC)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:RAE
Last Name:COSBY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:RAE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1403 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139
Mailing Address - Country:US
Mailing Address - Phone:314-955-9355
Mailing Address - Fax:
Practice Address - Street 1:5960 HOWDERSHELL RD STE 204
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-4103
Practice Address - Country:US
Practice Address - Phone:314-895-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013980111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner