Healthcare Provider Details

I. General information

NPI: 1912962291
Provider Name (Legal Business Name): SUSAN L BYERLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E WALNUT ST
ELLINGTON MO
63638-7943
US

IV. Provider business mailing address

PO BOX 989
POPLAR BLUFF MO
63902-0989
US

V. Phone/Fax

Practice location:
  • Phone: 573-663-2571
  • Fax: 573-663-2779
Mailing address:
  • Phone: 573-778-0020
  • Fax: 573-778-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number131216
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: