=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528500766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN R HANIFY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2016
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 STATE HIGHWAY 47
-----------------------------------------------------
City | MARTHASVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63357-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-266-7365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776084
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-364-7586
-----------------------------------------------------
Fax | 314-645-3801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2016033277
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------