Healthcare Provider Details

I. General information

NPI: 1063190940
Provider Name (Legal Business Name): AMANDA DAWN DARRIS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S JEFFERSON AVE
SPRINGFIELD MO
65806-2202
US

IV. Provider business mailing address

427 E CHERRY ST
SPRINGFIELD MO
65806-3305
US

V. Phone/Fax

Practice location:
  • Phone: 417-536-0061
  • Fax:
Mailing address:
  • Phone: 417-209-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2020020264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: