Healthcare Provider Details

I. General information

NPI: 1306664362
Provider Name (Legal Business Name): CLARE VERDA HEITZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WESTMINSTER AVE
FULTON MO
65251-1299
US

IV. Provider business mailing address

501 WESTMINSTER AVE
FULTON MO
65251-1299
US

V. Phone/Fax

Practice location:
  • Phone: 800-888-9266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2026033859
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: