Provider Demographics
NPI:1174662357
Name:FLYGARE, STEPHANIE L (MS, PA-C, LPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:FLYGARE
Suffix:
Gender:F
Credentials:MS, PA-C, LPC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:HOLTMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1736 E SUNSHINE ST STE 718
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1369
Mailing Address - Country:US
Mailing Address - Phone:417-860-3893
Mailing Address - Fax:417-877-0129
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-865-3479
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002489101YP2500X
MO2019005000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499799815Medicaid
MO499799815Medicaid