Healthcare Provider Details

I. General information

NPI: 1720713225
Provider Name (Legal Business Name): SARA KOSTELNICK MS, RD, LD, ACSM-CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 E REPUBLIC RD STE A
SPRINGFIELD MO
65804-7204
US

IV. Provider business mailing address

1311 E REPUBLIC RD STE A
SPRINGFIELD MO
65804-7204
US

V. Phone/Fax

Practice location:
  • Phone: 417-720-3670
  • Fax:
Mailing address:
  • Phone: 417-720-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number2020037369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: