Healthcare Provider Details

I. General information

NPI: 1851052427
Provider Name (Legal Business Name): HEATHER NICCOLE RICHARDSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S RANGE LINE RD
JOPLIN MO
64804-3234
US

IV. Provider business mailing address

1717 S RANGE LINE RD STE B
JOPLIN MO
64804-3224
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-2207
  • Fax:
Mailing address:
  • Phone: 417-623-2207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022002215
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number205734
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: