Healthcare Provider Details

I. General information

NPI: 1861944415
Provider Name (Legal Business Name): AMBER RENE MAPLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 PHYSICIANS PARK STE 200
POPLAR BLUFF MO
63901-3921
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-5500
  • Fax: 573-313-3684
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016040140
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2013007050
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: