Healthcare Provider Details

I. General information

NPI: 1609500990
Provider Name (Legal Business Name): DALTON LUSK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 E OLD STONE AVE
BROOKLINE MO
65619-9620
US

IV. Provider business mailing address

3203 E OLD STONE AVE
BROOKLINE MO
65619-9620
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-1910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022024064
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: