Healthcare Provider Details

I. General information

NPI: 1942510102
Provider Name (Legal Business Name): CAROLYN SUE CANTERBURY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 AGUILAR DR
MONTGOMERY CITY MO
63361-2723
US

IV. Provider business mailing address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax: 573-582-1212
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2010033156
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: