Healthcare Provider Details

I. General information

NPI: 1689322679
Provider Name (Legal Business Name): LIANNA STOVER HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WALTON DR
FARMINGTON MO
63640-1935
US

IV. Provider business mailing address

620 WALTON DR
FARMINGTON MO
63640-1935
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-0500
  • Fax: 573-756-0505
Mailing address:
  • Phone: 573-756-0500
  • Fax: 573-756-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2022009349
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: