Basic Information
| Provider Information | |||||||||
| NPI: | 1528043767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOTLE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AGOSTA | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1465 S GRAND BLVD | ||||||||
| Address2: | 01 OFFICE ROOM #2730 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142682700 | ||||||||
| FaxNumber: | 3142682775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 S GRAND BLVD | ||||||||
| Address2: | 01 OFFICE ROOM #2730 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145775647 | ||||||||
| FaxNumber: | 3142682775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 019009 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 2001019009 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 427362207 | 05 | MO | MEDICAID |