Healthcare Provider Details

I. General information

NPI: 1962143180
Provider Name (Legal Business Name): KYLIE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 E BATTLEFIELD RD
SPRINGFIELD MO
65804-3704
US

IV. Provider business mailing address

1518 E BATTLEFIELD RD
SPRINGFIELD MO
65804-3704
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-5530
  • Fax: 417-889-4071
Mailing address:
  • Phone: 417-881-5530
  • Fax: 417-889-4071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2022026133
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2509
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: