Healthcare Provider Details

I. General information

NPI: 1093936585
Provider Name (Legal Business Name): KATIE ELIZABETH HERN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR STE 230
ROLLA MO
65401-2931
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6350
  • Fax: 573-458-6764
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010013487
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: