Healthcare Provider Details

I. General information

NPI: 1356366405
Provider Name (Legal Business Name): SUSAN M GUTIERREZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

100 MERCY WAY
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-2300
  • Fax: 417-556-2906
Mailing address:
  • Phone: 417-556-2300
  • Fax: 417-556-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number125666
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: