1255463105 NPI number — MALISSA SHULL OT

Table of content: MALISSA SHULL OT (NPI 1255463105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255463105 NPI number — MALISSA SHULL OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHULL
Provider First Name:
MALISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255463105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 SE SUNNYSIDE SCHOOL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64014-3679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-220-3900
Provider Business Mailing Address Fax Number:
816-220-0877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 NW SAINT MARY DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BLUE SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64014-2524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-220-3900
Provider Business Practice Location Address Fax Number:
816-220-0877
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  2006012395 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37008018 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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