Healthcare Provider Details

I. General information

NPI: 1881717619
Provider Name (Legal Business Name): KIMBERLY FULLER ENSMINGER MCD, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY LUE ENSMINGER MCD, CCC-SLP

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N MADISON ST
WEBB CITY MO
64870-1238
US

IV. Provider business mailing address

9146 COUNTY LANE 209
WEBB CITY MO
64870-9125
US

V. Phone/Fax

Practice location:
  • Phone: 417-673-6000
  • Fax:
Mailing address:
  • Phone: 417-673-2392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2006015794
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: