Healthcare Provider Details

I. General information

NPI: 1023637071
Provider Name (Legal Business Name): CASEY LANE TRUITT RN, BSN, CCRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

6202 W BUCKEYE DR
ROGERS AR
72758-6050
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-3729
  • Fax:
Mailing address:
  • Phone: 417-861-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2015020712
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: