Provider Demographics
NPI:1003436411
Name:FOURNIER, KELLY L (CPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:FOURNIER
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S SMALLEY ST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7829
Mailing Address - Country:US
Mailing Address - Phone:931-209-0771
Mailing Address - Fax:
Practice Address - Street 1:105 S SMALLEY ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7829
Practice Address - Country:US
Practice Address - Phone:931-209-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20020019176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife