=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699113019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN MITCHELL D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2013
-----------------------------------------------------
Last Update Date | 01/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5381 HIGHWAY N STE 101
-----------------------------------------------------
City | COTTLEVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63304-7750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-875-7865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9556 MANCHESTER RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2020012107
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------