Healthcare Provider Details

I. General information

NPI: 1386272425
Provider Name (Legal Business Name): RACHEL BURLISON HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 ANWIJO WAY
WARRENTON MO
63383-1388
US

IV. Provider business mailing address

44 HAMPTON VILLAGE PLZ
SAINT LOUIS MO
63109-2127
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-7666
  • Fax:
Mailing address:
  • Phone: 314-481-6005
  • Fax: 314-481-4272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2020008332
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: