Healthcare Provider Details

I. General information

NPI: 1679717417
Provider Name (Legal Business Name): LAUREN GORDON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3247 GEYER AVE
SAINT LOUIS MO
63104-1520
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5666
  • Fax:
Mailing address:
  • Phone: 314-258-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2003017774
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: