=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497309595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. BRENDA LEE CARPENTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 07/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18724 N LOCUST GROVE RD
-----------------------------------------------------
City | STURGEON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65284-9129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-999-9423
-----------------------------------------------------
Fax | 573-387-4325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18724 N LOCUST GROVE RD
-----------------------------------------------------
City | STURGEON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65284-9129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-999-9423
-----------------------------------------------------
Fax | 573-387-4325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | LC001618584
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------