Healthcare Provider Details

I. General information

NPI: 1750512042
Provider Name (Legal Business Name): VICKY LAURINE SIMBRO RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 COVE RD
OSAGE BEACH MO
65065-2307
US

IV. Provider business mailing address

4505 COVE RD
OSAGE BEACH MO
65065-2307
US

V. Phone/Fax

Practice location:
  • Phone: 573-552-8525
  • Fax:
Mailing address:
  • Phone: 573-552-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number125894
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: