Healthcare Provider Details

I. General information

NPI: 1518995422
Provider Name (Legal Business Name): KRISTYN PONCY MENENDEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax: 660-890-8722
Mailing address:
  • Phone: 660-885-8171
  • Fax: 660-890-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2007005534
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: