Healthcare Provider Details

I. General information

NPI: 1164786166
Provider Name (Legal Business Name): KIA S LANNAMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BELLEVUE AVE STE 400
SAINT LOUIS MO
63117-1858
US

IV. Provider business mailing address

6420 CLAYTON RD STE 2800
SAINT LOUIS MO
63117-1811
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-7455
  • Fax:
Mailing address:
  • Phone: 314-768-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number4301105762
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number2017029226
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: