Provider Demographics
NPI:1881267714
Name:LAWRENCE, KYARA
Entity type:Individual
Prefix:
First Name:KYARA
Middle Name:
Last Name:LAWRENCE
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 1:720 OLIVE ST APT 506
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-2316
Mailing Address - Country:US
Mailing Address - Phone:314-601-1643
Mailing Address - Fax:
Practice Address - Street 1:720 OLIVE ST APT 506
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-2316
Practice Address - Country:US
Practice Address - Phone:314-601-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1568038339Medicaid
MO863251253Medicaid