Basic Information
Provider Information | |||||||||
NPI: | 1477525152 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VINYARD | ||||||||
FirstName: | ELISA | ||||||||
MiddleName: | EH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KIEHL | ||||||||
OtherFirstName: | ELISA | ||||||||
OtherMiddleName: | EH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1007 S POLK ST | ||||||||
Address2: |   | ||||||||
City: | MAYSVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 644694030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164492123 | ||||||||
FaxNumber: | 8164492125 | ||||||||
Practice Location | |||||||||
Address1: | 1007 S POLK ST | ||||||||
Address2: |   | ||||||||
City: | MAYSVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 644694030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164492123 | ||||||||
FaxNumber: | 8164492125 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20010215838 | MO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.