Healthcare Provider Details

I. General information

NPI: 1245566314
Provider Name (Legal Business Name): MELISSA SUE MASONBRINK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26136 US HIGHWAY 59
FAIRFAX MO
64446-8155
US

IV. Provider business mailing address

26136 US HIGHWAY 59
FAIRFAX MO
64446-8155
US

V. Phone/Fax

Practice location:
  • Phone: 660-686-2211
  • Fax: 660-686-2618
Mailing address:
  • Phone: 660-686-2211
  • Fax: 660-686-2618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2005038114
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: