Healthcare Provider Details

I. General information

NPI: 1164062998
Provider Name (Legal Business Name): DUSTIN SHANE MORTON PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S WASHINGTON ST
FARMINGTON MO
63640-1836
US

IV. Provider business mailing address

PO BOX 1255
FARMINGTON MO
63640-4176
US

V. Phone/Fax

Practice location:
  • Phone: 573-664-1047
  • Fax: 573-218-0716
Mailing address:
  • Phone: 573-664-1047
  • Fax: 573-218-0716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020004280
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: