Healthcare Provider Details

I. General information

NPI: 1639985773
Provider Name (Legal Business Name): KAYELIN HATHORN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 S NATIONAL AVE STE 600
SPRINGFIELD MO
65807-5249
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2024047334
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2024047334
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number2024047334
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2024047334
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2024047334
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: