MEDICARE: JUANITA K. LAWRENCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2011041766	MO

General Provider Information

NPI Number	:	1023691748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA K. LAWRENCE

Provider Business Mailing Address
First Line	:	1601 OLD SOUTH RIVER RD
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-4120
Country	:	US
Telephone Number	:	636-224-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	4928 DELMAR BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1615
Country	:	US
Telephone Number	:	314-899-0846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2021
Last Update Date	:	04/30/2021

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