Healthcare Provider Details

I. General information

NPI: 1750977278
Provider Name (Legal Business Name): LAUREN MORAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S BALLAS RD STE 6017B
SAINT LOUIS MO
63122-5315
US

IV. Provider business mailing address

510 S GORE AVE
SAINT LOUIS MO
63119-3704
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-4659
  • Fax: 314-251-5715
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2020033395
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: