Healthcare Provider Details

I. General information

NPI: 1376055004
Provider Name (Legal Business Name): MRS. JENNY VIVIAN HAWTHORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 MEXICO RD
O FALLON MO
63366-7507
US

IV. Provider business mailing address

8600 MEXICO RD
O FALLON MO
63366-7507
US

V. Phone/Fax

Practice location:
  • Phone: 636-202-0721
  • Fax: 636-600-5041
Mailing address:
  • Phone: 636-202-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2013031244
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20180009355
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: