Healthcare Provider Details

I. General information

NPI: 1982171997
Provider Name (Legal Business Name): LORA RODINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 W CATALPA ST
SPRINGFIELD MO
65807-1123
US

IV. Provider business mailing address

118 N 2ND ST
SAINT CHARLES MO
63301-2832
US

V. Phone/Fax

Practice location:
  • Phone: 417-862-3455
  • Fax: 417-862-9771
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-946-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2013006803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: