Healthcare Provider Details

I. General information

NPI: 1255924809
Provider Name (Legal Business Name): LARA TAYLOR APRN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 N TRUMAN BLVD
FESTUS MO
63028-1177
US

IV. Provider business mailing address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-2243
  • Fax:
Mailing address:
  • Phone: 636-236-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number2021004251
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2021004251
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: