Healthcare Provider Details

I. General information

NPI: 1194291054
Provider Name (Legal Business Name): AMY LALLATHIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 STATE HIGHWAY 248 STE 120
BRANSON MO
65616-3725
US

IV. Provider business mailing address

448 STATE HIGHWAY 248 STE 120
BRANSON MO
65616-3725
US

V. Phone/Fax

Practice location:
  • Phone: 417-337-5000
  • Fax:
Mailing address:
  • Phone: 417-337-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2018040401
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2014002993
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: