Healthcare Provider Details

I. General information

NPI: 1558047936
Provider Name (Legal Business Name): DAVID MICHAEL BAKER LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 OAKRIDGE DR
MARYVILLE IL
62062-6676
US

IV. Provider business mailing address

912 OAKRIDGE DR
MARYVILLE IL
62062-6676
US

V. Phone/Fax

Practice location:
  • Phone: 618-977-8950
  • Fax:
Mailing address:
  • Phone: 618-977-8950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2023021980
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057004598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: