Healthcare Provider Details

I. General information

NPI: 1013064898
Provider Name (Legal Business Name): PATRICIA KAY BOUSE RNC WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W 4TH ST
APPLETON CITY MO
64724-1402
US

IV. Provider business mailing address

424 SE 100TH RD
CLINTON MO
64735-9442
US

V. Phone/Fax

Practice location:
  • Phone: 660-476-2194
  • Fax: 660-476-9241
Mailing address:
  • Phone: 660-885-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number059306
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier29823019PIN 29824017
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier070058
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: