Healthcare Provider Details

I. General information

NPI: 1124219100
Provider Name (Legal Business Name): MELISSA DEANNE PRINCIVALLI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 09/12/2022
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOSPITAL DR
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-1255
  • Fax: 573-884-6942
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2004020809
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020034241
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: