MEDICARE: MS. CAROLYN SUE LUNDGREN C.P.N.P.

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	363LP0200X	Pediatric Nurse Practitioner	066304	MO

General Provider Information

NPI Number	:	1083728240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLYN SUE LUNDGREN C.P.N.P.

Provider Business Mailing Address
First Line	:	714 GRAVOIS RD
Second Line	:	STE. 200
City	:	FENTON
State	:	MO
Zip	:	63026-7727
Country	:	US
Telephone Number	:	636-349-5437
Fax Number	:	636-349-6663

Provider Business Practice Location Address
First Line	:	714 GRAVOIS RD
Second Line	:	STE. 200
City	:	FENTON
State	:	MO
Zip	:	63026-7727
Country	:	US
Telephone Number	:	636-349-5437
Fax Number	:	636-349-6663

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	07/08/2007

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