Provider Demographics
NPI:1023441672
Name:RECKTENWALD, KIRSTIE R (FNP)
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:R
Last Name:RECKTENWALD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-4754
Mailing Address - Country:US
Mailing Address - Phone:417-255-1373
Mailing Address - Fax:
Practice Address - Street 1:1409 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-4754
Practice Address - Country:US
Practice Address - Phone:417-255-1373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013024398207Y00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1023441672Medicaid
MO1023441672Medicaid