Provider Demographics
NPI:1528043767
Name:HOTLE, LAURA MARIE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:HOTLE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:AGOSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:01 OFFICE ROOM #2730
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-268-2700
Mailing Address - Fax:314-268-2775
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:01 OFFICE ROOM #2730
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5647
Practice Address - Fax:314-268-2775
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO019009363LP0200X
MO2001019009363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427362207Medicaid