=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962134114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIRCLE MAKER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 03/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 W MOUNT VERNON BLVD
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65712-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-461-0056
-----------------------------------------------------
Fax | 833-707-1944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 W MOUNT VERNON BLVD
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65712-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-461-0056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. LISA LYNN PARKER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 417-461-3009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------