MEDICARE: MRS. MAKENZIE SUE LAROSE NP

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	363L00000X	Nurse Practitioner	2017027611	MO
2	207Q00000X	Family Medicine Physician	2017027611	MO

General Provider Information

NPI Number	:	1881100766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MAKENZIE SUE LAROSE NP

Provider Business Mailing Address
First Line	:	352 S BROADVIEW ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63703
Country	:	US
Telephone Number	:	573-275-6446
Fax Number	:	573-313-3713

Provider Business Practice Location Address
First Line	:	352 S BROADVIEW ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63703
Country	:	US
Telephone Number	:	573-275-6446
Fax Number	:	573-313-3713

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

Provider Enumeration Date	:	12/14/2017
Last Update Date	:	12/01/2025

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