Healthcare Provider Details

I. General information

NPI: 1962523290
Provider Name (Legal Business Name): MARY R LAWRENCE RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD ST. ANTHONY MEDICAL CENTER, DIABETES EDUCATION
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10010 KENNERLY RD ST. ANTHONY MEDICAL CENTER, DIABETES EDUCATION
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4506
  • Fax: 314-525-4260
Mailing address:
  • Phone: 314-525-4506
  • Fax: 314-525-4260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number063270
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: