Provider Demographics
NPI:1811346158
Name:MARRIOTT, LAURICA
Entity type:Individual
Prefix:
First Name:LAURICA
Middle Name:
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:MO
Mailing Address - Zip Code:65548-7109
Mailing Address - Country:US
Mailing Address - Phone:417-256-9111
Mailing Address - Fax:
Practice Address - Street 1:220 N ELM ST.
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:MO
Practice Address - Zip Code:65548-8347
Practice Address - Country:US
Practice Address - Phone:417-247-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009021791163W00000X
MOF0616628363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811346158Medicaid