Healthcare Provider Details

I. General information

NPI: 1093186579
Provider Name (Legal Business Name): HANNAH KATHERINE DALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55774, 6 STATE HWY D
EDINA MO
63537
US

IV. Provider business mailing address

54463 FOXTROT AVE
KNOX CITY MO
63446-4036
US

V. Phone/Fax

Practice location:
  • Phone: 660-397-2282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2015024298
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: