Provider Demographics
NPI:1063675817
Name:FOSTER, MANDY JO (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:JO
Last Name:FOSTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E PRATT ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2154
Mailing Address - Country:US
Mailing Address - Phone:636-209-1063
Mailing Address - Fax:
Practice Address - Street 1:715 E PRATT ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2154
Practice Address - Country:US
Practice Address - Phone:636-209-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001017861173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist