Healthcare Provider Details

I. General information

NPI: 1639863814
Provider Name (Legal Business Name): GRACE BUTTERFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE # PROF160
SPRINGFIELD MO
65897-0001
US

IV. Provider business mailing address

428 S MAIN AVE
SPRINGFIELD MO
65806-2018
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5000
  • Fax:
Mailing address:
  • Phone: 402-708-2870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: