Healthcare Provider Details

I. General information

NPI: 1114277803
Provider Name (Legal Business Name): JENNIFER LEANN BADER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEANN LAWRENCE FNP

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 KENNETT ST
KENNETT MO
63857-3817
US

IV. Provider business mailing address

6738 STATE HIGHWAY 77
BENTON MO
63736-8238
US

V. Phone/Fax

Practice location:
  • Phone: 573-717-1130
  • Fax:
Mailing address:
  • Phone: 573-313-2500
  • Fax: 573-313-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2005022001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: