Healthcare Provider Details

I. General information

NPI: 1295465110
Provider Name (Legal Business Name): HALEIGH MCKENZIE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALEIGH WOSMAN

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 COMMUNICATION DR
HANNIBAL MO
63401-3670
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 573-603-1460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2022020207
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: