Healthcare Provider Details

I. General information

NPI: 1093393977
Provider Name (Legal Business Name): PROF. KAYARA LACINE UPCHURCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 WEDGE DR
SAINT LOUIS MO
63135-2242
US

IV. Provider business mailing address

9729 PORTAGE DR
SAINT LOUIS MO
63136-5311
US

V. Phone/Fax

Practice location:
  • Phone: 314-701-0100
  • Fax:
Mailing address:
  • Phone: 612-369-7082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number2001023410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: