Healthcare Provider Details

I. General information

NPI: 1528043767
Provider Name (Legal Business Name): LAURA MARIE HOTLE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA MARIE AGOSTA CPNP

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD 01 OFFICE ROOM #2730
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD 01 OFFICE ROOM #2730
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5647
  • Fax: 314-268-2775
Mailing address:
  • Phone: 314-268-2700
  • Fax: 314-268-2775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number019009
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2001019009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: