Provider Demographics
NPI:1619556016
Name:BREAULT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BREAULT
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:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-1240
Mailing Address - Country:US
Mailing Address - Phone:417-546-4200
Mailing Address - Fax:417-546-4505
Practice Address - Street 1:256 STATE HIGHWAY Y
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653-5618
Practice Address - Country:US
Practice Address - Phone:417-546-4200
Practice Address - Fax:417-546-4505
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021011336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021011336OtherLICENSE NUMBER