Basic Information
| Provider Information | |||||||||
| NPI: | 1235637562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMGE | ||||||||
| FirstName: | KACY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAFFER | ||||||||
| OtherFirstName: | KACY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD, LD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
| FaxNumber: | 3148514445 | ||||||||
| Practice Location | |||||||||
| Address1: | 12655 OLIVE BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
| FaxNumber: | 3148514445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2018009252 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.