Healthcare Provider Details

I. General information

NPI: 1538477781
Provider Name (Legal Business Name): LAURIE SEWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKINGS DR
SAINT LOUIS MO
63130-4862
US

IV. Provider business mailing address

1 BROOKINGS DR CB 1201
SAINT LOUIS MO
63130-4862
US

V. Phone/Fax

Practice location:
  • Phone: 314-935-6666
  • Fax: 314-935-8515
Mailing address:
  • Phone: 314-935-6666
  • Fax: 314-935-8515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2010033323
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: