Healthcare Provider Details

I. General information

NPI: 1104194810
Provider Name (Legal Business Name): JENNIFER ANN NYLUND MS, RCEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1600 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-5511
  • Fax: 660-890-7198
Mailing address:
  • Phone: 660-885-5511
  • Fax: 660-890-7198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number629235
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: