Provider Demographics
NPI:1770949406
Name:MUNTHALI, GRACE GOMBE (APRN, NP,RN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:GOMBE
Last Name:MUNTHALI
Suffix:
Gender:F
Credentials:APRN, NP,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1753
Mailing Address - Country:US
Mailing Address - Phone:573-592-3409
Mailing Address - Fax:
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-592-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010002416163W00000X
MO2015025656363LF0000X
MO2018012589363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily