Healthcare Provider Details

I. General information

NPI: 1619862711
Provider Name (Legal Business Name): ELISA MULKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 S TRUMAN BLVD
FESTUS MO
63028-2234
US

IV. Provider business mailing address

1002 N TAYLOR AVE
CRYSTAL CITY MO
63019-1210
US

V. Phone/Fax

Practice location:
  • Phone: 636-777-4679
  • Fax:
Mailing address:
  • Phone: 314-602-0862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2025024087
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: