Provider Demographics
NPI:1881100766
Name:LAROSE, MAKENZIE SUE (APRN FNP BC)
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:SUE
Last Name:LAROSE
Suffix:
Gender:F
Credentials:APRN FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 LACEY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5230
Mailing Address - Country:US
Mailing Address - Phone:573-334-4822
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-334-4822
Practice Address - Fax:573-334-4822
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017027611363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner