Provider Demographics
NPI:1619782299
Name:GRANDERSON, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GRANDERSON
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 1:9616 SAINT GIRARD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-3932
Mailing Address - Country:US
Mailing Address - Phone:314-393-5537
Mailing Address - Fax:
Practice Address - Street 1:1515 N WARSON RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1108
Practice Address - Country:US
Practice Address - Phone:314-393-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health