Healthcare Provider Details

I. General information

NPI: 1952811705
Provider Name (Legal Business Name): MINETTE JANE WOOLVEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-3413
  • Fax: 417-347-3609
Mailing address:
  • Phone: 417-347-3649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017035517
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number2017035517
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: