Healthcare Provider Details

I. General information

NPI: 1487661666
Provider Name (Legal Business Name): LORNA DIANNE STOOKEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORNA DIANNE SHAW M.D.

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

IV. Provider business mailing address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-4111
  • Fax: 573-783-1096
Mailing address:
  • Phone: 573-783-4111
  • Fax: 573-783-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005034478
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-0-78975
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: