Healthcare Provider Details

I. General information

NPI: 1598298457
Provider Name (Legal Business Name): SUMMER DENAE TIPTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 S HILLCREST AVE
SPRINGFIELD MO
65807-2108
US

IV. Provider business mailing address

2140 S HILLCREST AVE
SPRINGFIELD MO
65807-2108
US

V. Phone/Fax

Practice location:
  • Phone: 417-987-8306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2017005571
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: