Healthcare Provider Details

I. General information

NPI: 1366530628
Provider Name (Legal Business Name): BRENDA M. CUPP DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY SUITE 320-330
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

100 MERCY WAY SUITE 320-330
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-5387
  • Fax: 417-781-7174
Mailing address:
  • Phone: 417-781-5387
  • Fax: 417-781-7174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: