Healthcare Provider Details

I. General information

NPI: 1215518014
Provider Name (Legal Business Name): MACY FAYE MANIER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACY FAYE SHIVELY

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-0330
  • Fax: 573-471-0461
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024018583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: