Healthcare Provider Details

I. General information

NPI: 1215968714
Provider Name (Legal Business Name): SUE T LAZARUS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 W 32ND ST STE 201
JOPLIN MO
64804-1607
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-8660
  • Fax: 417-347-8691
Mailing address:
  • Phone: 417-347-8660
  • Fax: 417-347-8691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number53-64037
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number2003031877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: