Healthcare Provider Details

I. General information

NPI: 1780200113
Provider Name (Legal Business Name): HANNAH JO BRAUNGARDT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. HANNAH JO BRAUNGARDT GOODWIN

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E JACKSON ST
EDINA MO
63537-1335
US

IV. Provider business mailing address

104 E JACKSON ST
EDINA MO
63537-1335
US

V. Phone/Fax

Practice location:
  • Phone: 660-397-3517
  • Fax: 660-397-2307
Mailing address:
  • Phone: 660-397-3517
  • Fax: 660-397-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023025344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: