Healthcare Provider Details

I. General information

NPI: 1801466784
Provider Name (Legal Business Name): CARISSA BAILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

1044 E HIGHPOINT ST
SPRINGFIELD MO
65810-2939
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax:
Mailing address:
  • Phone: 417-207-9546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202024178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: