Provider Demographics
NPI:1447825203
Name:FALCONER, LAUREN DERMODY (OD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:DERMODY
Last Name:FALCONER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16508 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1217
Mailing Address - Country:US
Mailing Address - Phone:636-273-6336
Mailing Address - Fax:
Practice Address - Street 1:16508 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1217
Practice Address - Country:US
Practice Address - Phone:636-273-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021020700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program