Healthcare Provider Details

I. General information

NPI: 1619556016
Provider Name (Legal Business Name): STEPHANIE BREAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 STATE HIGHWAY Y
FORSYTH MO
65653-5618
US

IV. Provider business mailing address

PO BOX 1240
FORSYTH MO
65653-1240
US

V. Phone/Fax

Practice location:
  • Phone: 417-546-4200
  • Fax: 417-546-4505
Mailing address:
  • Phone: 417-546-4200
  • Fax: 417-546-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021011336
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: