Healthcare Provider Details

I. General information

NPI: 1720621154
Provider Name (Legal Business Name): ASHLEY LAINE HODGES MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY LAINE EVANS RN

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 MEDICAL DR
HANNIBAL MO
63401-6877
US

IV. Provider business mailing address

188 MEDICAL DR
HANNIBAL MO
63401-6877
US

V. Phone/Fax

Practice location:
  • Phone: 573-248-1010
  • Fax: 573-231-0046
Mailing address:
  • Phone: 573-248-1010
  • Fax: 573-231-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number2002015387
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019036577
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: