Healthcare Provider Details

I. General information

NPI: 1639143928
Provider Name (Legal Business Name): FAYE DENISE HUDSON A.T.,C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4331 S FREMONT AVE
SPRINGFIELD MO
65804-7328
US

IV. Provider business mailing address

281 E KATIE DR
SPRINGFIELD MO
65803-4577
US

V. Phone/Fax

Practice location:
  • Phone: 471-820-5010
  • Fax: 417-820-5022
Mailing address:
  • Phone: 417-833-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2005038356
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: