Healthcare Provider Details

I. General information

NPI: 1558623215
Provider Name (Legal Business Name): MARY L LAGES MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY L LAGES MSN

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-894-6496
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-894-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number055395
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: