Healthcare Provider Details

I. General information

NPI: 1417723487
Provider Name (Legal Business Name): BRANDI NICOLE LUNSFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WALNUT ST
DONIPHAN MO
63935-1400
US

IV. Provider business mailing address

401 WALNUT ST
DONIPHAN MO
63935-1400
US

V. Phone/Fax

Practice location:
  • Phone: 573-996-3667
  • Fax:
Mailing address:
  • Phone: 573-996-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number2026028985
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: