Individual
DESYRAE ELIZA RIDENOUR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
960 E WALNUT LAWN ST STE 201, SPRINGFIELD, MO 65807-7865
(417) 269-4450
(417) 269-4470
Mailing address
PO BOX 505673, SAINT LOUIS, MO 63150-5673
(417) 730-6430
(417) 269-7567
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2024003095
MO
Other
Enumeration date
01/29/2024
Last updated
04/30/2024
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