Healthcare Provider Details

I. General information

NPI: 1679114722
Provider Name (Legal Business Name): KAYLA JEAN BLAES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304A E 4TH ST
ELDON MO
65026-1808
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-557-2400
  • Fax: 573-557-2401
Mailing address:
  • Phone: 573-348-8399
  • Fax: 573-348-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019036877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: