1356615538 NPI number — MRS. SHAYNA LEIGH LARAMORE RN

Table of content: MRS. SHAYNA LEIGH LARAMORE RN (NPI 1356615538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356615538 NPI number — MRS. SHAYNA LEIGH LARAMORE RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARAMORE
Provider First Name:
SHAYNA
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FALLERT
Provider Other First Name:
SHAYNA
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356615538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12639 OLD TESSON RD
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-849-0311
Provider Business Mailing Address Fax Number:
314-849-4423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12639 OLD TESSON RD
Provider Second Line Business Practice Location Address:
SUITE
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-849-0311
Provider Business Practice Location Address Fax Number:
314-849-4423
Provider Enumeration Date:
03/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2012041255 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122950074 . This is a "PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P01143937 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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