Provider Demographics
NPI:1740059294
Name:MOSLEY, SHERRY M
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:M
Last Name:MOSLEY
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 1:400 SOUTH AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2183
Mailing Address - Country:US
Mailing Address - Phone:417-824-0162
Mailing Address - Fax:
Practice Address - Street 1:17094 MARTIN PEDRO RD
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-8532
Practice Address - Country:US
Practice Address - Phone:417-824-0162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOL167201009172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver