Healthcare Provider Details

I. General information

NPI: 1194316109
Provider Name (Legal Business Name): LAQUETTE ANDERSON MEDCALF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 MAYBELLE DR
SAINT LOUIS MO
63121-4119
US

IV. Provider business mailing address

3209 MAYBELLE DR
SAINT LOUIS MO
63121-4119
US

V. Phone/Fax

Practice location:
  • Phone: 314-536-6991
  • Fax:
Mailing address:
  • Phone: 314-536-6991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: