Healthcare Provider Details

I. General information

NPI: 1760966188
Provider Name (Legal Business Name): MRS. MANDI NICOLE PARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35629 HIGHWAY 72
SALEM MO
65560-7217
US

IV. Provider business mailing address

PO BOX 213
SALEM MO
65560-0213
US

V. Phone/Fax

Practice location:
  • Phone: 573-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018036147
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: