Healthcare Provider Details

I. General information

NPI: 1255696001
Provider Name (Legal Business Name): AMANDA ELAINE BADER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 S WALNUT ST
BERNIE MO
63822-8900
US

IV. Provider business mailing address

420 SEMO DR P.O. BOX 400
NEW MADRID MO
63869-1734
US

V. Phone/Fax

Practice location:
  • Phone: 573-293-6836
  • Fax: 573-293-6838
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012022612
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: