Healthcare Provider Details

I. General information

NPI: 1619491024
Provider Name (Legal Business Name): TIFFANY RENEE KIRK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 W HUBBLE DR
MARSHFIELD MO
65706-1532
US

IV. Provider business mailing address

543 W HUBBLE DR
MARSHFIELD MO
65706-1532
US

V. Phone/Fax

Practice location:
  • Phone: 417-859-4878
  • Fax: 417-859-0889
Mailing address:
  • Phone: 417-859-4878
  • Fax: 417-859-0889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017024997
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: