Healthcare Provider Details

I. General information

NPI: 1174410534
Provider Name (Legal Business Name): JEPCHIRCHIR MUTWOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE
SPRINGFIELD MO
65807-5297
US

IV. Provider business mailing address

2005 W CHESTERFIELD BLVD APT 203
SPRINGFIELD MO
65807-8917
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-6000
  • Fax:
Mailing address:
  • Phone: 682-329-0961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2025023097
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2025023097
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: