Healthcare Provider Details

I. General information

NPI: 1427546852
Provider Name (Legal Business Name): MARY LAUREN SPENCER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
CREVE COEUR MO
63141
US

IV. Provider business mailing address

2905 SWEET FLAG CT
DARDENNE PRAIRIE MO
63368-9734
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6000
  • Fax:
Mailing address:
  • Phone: 314-550-6695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number2008020275
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number2018025958
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: