Healthcare Provider Details

I. General information

NPI: 1275918856
Provider Name (Legal Business Name): STEPHANIE DIANE WALKER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S BUSINESS 61
BOWLING GREEN MO
63334
US

IV. Provider business mailing address

2305 GEORGIA ST
LOUISIANA MO
63353-2559
US

V. Phone/Fax

Practice location:
  • Phone: 573-324-5562
  • Fax: 573-324-2567
Mailing address:
  • Phone: 573-754-4584
  • Fax: 573-754-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015023415
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: