Healthcare Provider Details

I. General information

NPI: 1629049929
Provider Name (Legal Business Name): JOSETTA ELIESE WAHWASSUCK MSN, FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S MILL ST
ELDON MO
65026-1864
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number096721
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number44870
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number096721
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: