Provider Demographics
NPI:1417067125
Name:KAUFMAN, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:KAUFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-2849
Mailing Address - Country:US
Mailing Address - Phone:573-620-1192
Mailing Address - Fax:
Practice Address - Street 1:913 W BUSINESS US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-2704
Practice Address - Country:US
Practice Address - Phone:573-624-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002016792OtherLICENSE #