Healthcare Provider Details

I. General information

NPI: 1609915958
Provider Name (Legal Business Name): KELLY GRACE GRAMKE MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N MAIN ST
LAURIE MO
65037-6173
US

IV. Provider business mailing address

10843 MCCASLAND RD
VERSAILLES MO
65084-5652
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-0767
  • Fax: 573-374-1399
Mailing address:
  • Phone: 573-378-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2001002512
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: