Healthcare Provider Details

I. General information

NPI: 1982142253
Provider Name (Legal Business Name): DAWN WADE APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W 30TH ST
JOPLIN MO
64804-1520
US

IV. Provider business mailing address

PO BOX 459
FARMINGTON MO
63640-0459
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020039518
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number150688
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: