Healthcare Provider Details

I. General information

NPI: 1669349213
Provider Name (Legal Business Name): CHARIS HEALTHCARE OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 KATELYN ST
KENNETT MO
63857-4112
US

IV. Provider business mailing address

1815 KATELYN ST
KENNETT MO
63857-4112
US

V. Phone/Fax

Practice location:
  • Phone: 870-489-8633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY LYNN MOORE
Title or Position: OWNER
Credential: ARPN
Phone: 870-489-8633