Healthcare Provider Details

I. General information

NPI: 1073279568
Provider Name (Legal Business Name): KELLI ELIZABETH BUNTAINE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2991 HIGHWAY K
O FALLON MO
63368-7862
US

IV. Provider business mailing address

2991 HIGHWAY K
O FALLON MO
63368-7862
US

V. Phone/Fax

Practice location:
  • Phone: 636-435-2333
  • Fax: 314-626-8009
Mailing address:
  • Phone: 636-435-2333
  • Fax: 314-626-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022015784
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number149260
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: