MEDICARE: MS. LAURA ELLIOTT FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2013035666	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MA1721	OTHER	MO	MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1598193187	OTHER	MO	NPI
2	1760626147	OTHER	MO	GROUP NPI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598193187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA ELLIOTT FNP-C

Provider Business Mailing Address
First Line	:	PO BOX 955534
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-5534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12277 DE PAUL DR STE 403
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2536
Country	:	US
Telephone Number	:	314-738-2715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2013
Last Update Date	:	11/18/2020

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