Healthcare Provider Details

I. General information

NPI: 1396613576
Provider Name (Legal Business Name): ALIX SHANTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 S CRADER CT
SPRINGFIELD MO
65802-9753
US

IV. Provider business mailing address

690 S CRADER CT
SPRINGFIELD MO
65802-9753
US

V. Phone/Fax

Practice location:
  • Phone: 417-343-2787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86114968
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: