Healthcare Provider Details

I. General information

NPI: 1689666778
Provider Name (Legal Business Name): CAROL TIMMONS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL SWAINE FNP

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N SHELBY ST PO BOX 132
CLARENCE MO
63437-1712
US

IV. Provider business mailing address

109 N SHELBY ST PO BOX 132
CLARENCE MO
63437-1712
US

V. Phone/Fax

Practice location:
  • Phone: 573-469-2084
  • Fax:
Mailing address:
  • Phone: 573-469-2084
  • Fax: 660-699-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number092882
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0327043
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: