Healthcare Provider Details

I. General information

NPI: 1811338767
Provider Name (Legal Business Name): AMY HARRELL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SOUTHWEST BLVD SUITE B
JEFFERSON CITY MO
65109-2472
US

IV. Provider business mailing address

1500 SOUTHWEST BLVD SUITE B
JEFFERSON CITY MO
65109-2472
US

V. Phone/Fax

Practice location:
  • Phone: 537-635-6350
  • Fax: 573-644-6657
Mailing address:
  • Phone: 537-635-6350
  • Fax: 573-644-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2013017567
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013017567
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: