Healthcare Provider Details

I. General information

NPI: 1134045362
Provider Name (Legal Business Name): LAKYN ELISE VAVRUSKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W MCCABE ST
STRAFFORD MO
65757-8206
US

IV. Provider business mailing address

568 STRAIGHT RD
CONWAY MO
65632-7120
US

V. Phone/Fax

Practice location:
  • Phone: 417-736-7000
  • Fax:
Mailing address:
  • Phone: 417-241-3704
  • Fax: 417-241-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2026028959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: