Healthcare Provider Details

I. General information

NPI: 1932742822
Provider Name (Legal Business Name): LAKEISHA PERRY AVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 11/27/2023
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 ARROWPOINT DR
SAINT LOUIS MO
63138-1515
US

IV. Provider business mailing address

5843 EAGLE VALLEY DR
SAINT LOUIS MO
63136-1148
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-5219
  • Fax:
Mailing address:
  • Phone: 314-308-5219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number2019028291
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: