Healthcare Provider Details

I. General information

NPI: 1598193187
Provider Name (Legal Business Name): LAURA ELLIOTT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12277 DE PAUL DR STE 403
BRIDGETON MO
63044-2536
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-738-2715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013035666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: