Healthcare Provider Details

I. General information

NPI: 1972823896
Provider Name (Legal Business Name): LAURIE ANN WERDEHAUSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE ANN GOETZ RN

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11179 COUNTY ROAD 391
HOLTS SUMMIT MO
65043-1304
US

IV. Provider business mailing address

11179 COUNTY ROAD 391
HOLTS SUMMIT MO
65043-1304
US

V. Phone/Fax

Practice location:
  • Phone: 573-694-7978
  • Fax:
Mailing address:
  • Phone: 573-694-7978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2004005088
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: