Healthcare Provider Details

I. General information

NPI: 1184746059
Provider Name (Legal Business Name): LARA GUBBINS SMITH RN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

4728 AUBURN TRACE DR
SAINT LOUIS MO
63128-2851
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2591
  • Fax:
Mailing address:
  • Phone: 314-660-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number137488
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number137488
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: