Healthcare Provider Details

I. General information

NPI: 1215636550
Provider Name (Legal Business Name): MRS. KALLAN ELAINE FIMPLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KALLAN ELAINE MURPHY

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E PRIMROSE ST
SPRINGFIELD MO
65804-7929
US

IV. Provider business mailing address

172 QUINCY RD
KIRBYVILLE MO
65679-9319
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-4700
  • Fax:
Mailing address:
  • Phone: 918-645-0579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2023004369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: