Provider Demographics
NPI:1518103654
Name:DANIELS, LACRETIA M (NP)
Entity type:Individual
Prefix:MS
First Name:LACRETIA
Middle Name:M
Last Name:DANIELS
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9354
Mailing Address - Country:US
Mailing Address - Phone:636-497-4055
Mailing Address - Fax:636-344-1069
Practice Address - Street 1:1520 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3408
Practice Address - Country:US
Practice Address - Phone:636-497-4055
Practice Address - Fax:636-344-1069
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO137786363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427204102Medicaid