Healthcare Provider Details

I. General information

NPI: 1265753792
Provider Name (Legal Business Name): FORSYTH FAMILY MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10726 E HWY 76 STE. G
FORSYTH MO
65653
US

IV. Provider business mailing address

PO BOX 1239
FORSYTH MO
65653-1239
US

V. Phone/Fax

Practice location:
  • Phone: 417-546-2590
  • Fax: 417-546-2594
Mailing address:
  • Phone: 417-546-2590
  • Fax: 417-546-2594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number120158
License Number StateMO

VIII. Authorized Official

Name: SHEILA LOUISE WYMAN
Title or Position: FNP / OWNER
Credential: FNP
Phone: 417-546-2590