Provider Demographics
NPI:1164691945
Name:SMITH, LAVADA JEAN (ANP)
Entity Type:Individual
Prefix:
First Name:LAVADA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO150496363LA2200X
IL2090200077363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164691945Medicaid
IL1164691945Medicaid
IL1164691945Medicaid