Healthcare Provider Details

I. General information

NPI: 1093715740
Provider Name (Legal Business Name): JUDITH G LEWALLEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH G KEETON FNP

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JESSIE JAMES BLVD
PINEVILLE MO
64856
US

IV. Provider business mailing address

100 JESSIE JAMES BLVD
PINEVILLE MO
64856
US

V. Phone/Fax

Practice location:
  • Phone: 417-223-7050
  • Fax: 417-223-7055
Mailing address:
  • Phone: 417-223-7050
  • Fax: 417-223-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1028
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number085477
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03622
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: