Healthcare Provider Details

I. General information

NPI: 1952842775
Provider Name (Legal Business Name): CENTRAL METHODIST UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ STE 204
FAYETTE MO
65248-1104
US

IV. Provider business mailing address

411 CENTRAL METHODIST SQ
FAYETTE MO
65248-1104
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-6285
  • Fax: 660-248-6266
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA CORINNE KIRKENDOLL
Title or Position: DIR OF STUDENT HEALTH SERV, FNP
Credential: MSN, APRN, NP-C
Phone: 660-248-6285