Healthcare Provider Details

I. General information

NPI: 1447702212
Provider Name (Legal Business Name): LAUREN ELAINE PETRY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 N JEFFERSON AVE STE K100
SPRINGFIELD MO
65802-1917
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-3915
  • Fax: 417-269-3913
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2007034599
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017008465
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: