Healthcare Provider Details

I. General information

NPI: 1811530496
Provider Name (Legal Business Name): CALLIE HEFNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N SPRIGG ST
CAPE GIRARDEAU MO
63701-2720
US

IV. Provider business mailing address

1710 N SPRIGG ST
CAPE GIRARDEAU MO
63701-2720
US

V. Phone/Fax

Practice location:
  • Phone: 618-306-1250
  • Fax:
Mailing address:
  • Phone: 618-306-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: