Healthcare Provider Details

I. General information

NPI: 1679943377
Provider Name (Legal Business Name): ANDREA GULLETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA AST

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 E OLD STONE RD
BROOKLINE MO
65619-9620
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-1910
  • Fax: 417-269-1916
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015021532
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: