Healthcare Provider Details

I. General information

NPI: 1487819637
Provider Name (Legal Business Name): KATHERINE G BUNN RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHY GILBERT RD LD

II. Dates (important events)

Enumeration Date: 07/26/2008
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY STE 580
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

100 MERCY WAY STE 580
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-8555
  • Fax:
Mailing address:
  • Phone: 417-556-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2007035386
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: