Healthcare Provider Details

I. General information

NPI: 1245959717
Provider Name (Legal Business Name): ASHLEY MARIE GANTNER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

IV. Provider business mailing address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-7575
  • Fax:
Mailing address:
  • Phone: 573-624-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022031216
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: