Healthcare Provider Details

I. General information

NPI: 1932201837
Provider Name (Legal Business Name): KRISTEN ANNE THEOBALD-HAZEL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 MEDICAL PARK DR
OSAGE BEACH MO
65065-3000
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-3100
  • Fax: 573-348-8279
Mailing address:
  • Phone: 573-302-3100
  • Fax: 573-348-8279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009001633
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1447229489
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: