Healthcare Provider Details

I. General information

NPI: 1639539141
Provider Name (Legal Business Name): MALLORY ELIZABETH STITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 1ST ST
KENNETT MO
63857-2525
US

IV. Provider business mailing address

40 KATHY CV
POPLAR BLUFF MO
63901-2095
US

V. Phone/Fax

Practice location:
  • Phone: 573-718-4038
  • Fax:
Mailing address:
  • Phone: 573-718-4038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2016005888
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: