Individual
MRS. KONGKEO THIKY WALTHER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ANP
Contact information
Practice address
12774 BOENKER LN, BRIDGETON, MO 63044-2436
(314) 291-7997
(314) 739-1471
Mailing address
PO BOX 776874, CHICAGO, IL 60677-6874
(314) 291-7997
(314) 739-1471
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
2015040094
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
420030952
—
MO
Enumeration date
12/03/2015
Last updated
12/21/2023
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