Healthcare Provider Details

I. General information

NPI: 1548385735
Provider Name (Legal Business Name): AMY B HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 MILLER ST
BETHANY MO
64424-2713
US

IV. Provider business mailing address

3202 MILLER ST
BETHANY MO
64424-2713
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-3154
  • Fax: 660-425-6663
Mailing address:
  • Phone: 660-425-3154
  • Fax: 660-425-6663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number138539
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: