Healthcare Provider Details

I. General information

NPI: 1902721731
Provider Name (Legal Business Name): MIKALY ETIANA ANNE FANDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 S CULPEPPER CIR STE D
SPRINGFIELD MO
65804-4251
US

IV. Provider business mailing address

350 S JOHN Q HAMMONS PKWY APT 9C APT 9C
SPRINGFIELD MO
65806-2502
US

V. Phone/Fax

Practice location:
  • Phone: 417-893-9359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: