Healthcare Provider Details

I. General information

NPI: 1528500766
Provider Name (Legal Business Name): LAUREN R HANIFY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN R NEIER

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STATE HIGHWAY 47
MARTHASVILLE MO
63357-1714
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-266-7365
  • Fax:
Mailing address:
  • Phone: 314-364-7586
  • Fax: 314-645-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2016033277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: