Healthcare Provider Details

I. General information

NPI: 1811346158
Provider Name (Legal Business Name): LAURICA MARRIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 05/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N ELM ST.
MOUNTAIN VIEW MO
65548-8347
US

IV. Provider business mailing address

PO BOX 32
MOUNTAIN VIEW MO
65548-7109
US

V. Phone/Fax

Practice location:
  • Phone: 417-247-5543
  • Fax:
Mailing address:
  • Phone: 417-256-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009021791
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0616628
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: