Healthcare Provider Details

I. General information

NPI: 1528630290
Provider Name (Legal Business Name): LANA RENE MCCLEASE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 GRAPE AVE
SAINT LOUIS MO
63147-1403
US

IV. Provider business mailing address

1549 GRAPE AVE
SAINT LOUIS MO
63147-1403
US

V. Phone/Fax

Practice location:
  • Phone: 314-601-4520
  • Fax:
Mailing address:
  • Phone: 314-601-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: