Healthcare Provider Details

I. General information

NPI: 1790452225
Provider Name (Legal Business Name): ANGELA THILL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA SPENCER

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MISSOURI BLVD
GRAVOIS MILLS MO
65037-5394
US

IV. Provider business mailing address

246 WHISPERING COVE DRIVE
CAMDENTON MO
65020
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-5263
  • Fax: 573-374-4933
Mailing address:
  • Phone: 515-708-5204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021029996
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: