Healthcare Provider Details

I. General information

NPI: 1568262699
Provider Name (Legal Business Name): LASYA DAGGUMATI
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 HOLMES ST
KANSAS CITY MO
64108-2741
US

IV. Provider business mailing address

147 ESSEN PLACE DR
BALLWIN MO
63011-3276
US

V. Phone/Fax

Practice location:
  • Phone: 704-453-8123
  • Fax:
Mailing address:
  • Phone: 704-453-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: