Healthcare Provider Details

I. General information

NPI: 1770949406
Provider Name (Legal Business Name): GRACE GOMBE MUNTHALI APRN, NP,RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 5TH ST
FULTON MO
65251-1753
US

IV. Provider business mailing address

600 E 5TH ST
FULTON MO
65251-1753
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-2623
  • Fax:
Mailing address:
  • Phone: 573-592-3409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010002416
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015025656
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2018012589
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: