Healthcare Provider Details

I. General information

NPI: 1376011007
Provider Name (Legal Business Name): LASHONDA S WASH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 BRUCE AVE
SAINT LOUIS MO
63135-2704
US

IV. Provider business mailing address

222 BRUCE AVE
SAINT LOUIS MO
63135-2704
US

V. Phone/Fax

Practice location:
  • Phone: 314-518-3679
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2016017520
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: