Healthcare Provider Details

I. General information

NPI: 1659606713
Provider Name (Legal Business Name): JILL M MCGRUDER APRN,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 LESTER ST
POPLAR BLUFF MO
63901-5025
US

IV. Provider business mailing address

686 LESTER ST
POPLAR BLUFF MO
63901-5025
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-2411
  • Fax: 573-686-8452
Mailing address:
  • Phone: 573-686-2411
  • Fax: 573-686-8452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number147615
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: