Healthcare Provider Details

I. General information

NPI: 1922129725
Provider Name (Legal Business Name): MARY HELEN FISHBURN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 N HWY CC
NIXA MO
65714-8015
US

IV. Provider business mailing address

720 S LIPSCOMB
REPUBLIC MO
65738-2282
US

V. Phone/Fax

Practice location:
  • Phone: 417-725-5774
  • Fax: 417-725-5915
Mailing address:
  • Phone: 417-732-9589
  • Fax: 417-732-9589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2001003375
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: