Healthcare Provider Details

I. General information

NPI: 1972593465
Provider Name (Legal Business Name): AMY KELLAMS STINNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E 3RD ST
PORTAGEVILLE MO
63873-1402
US

IV. Provider business mailing address

204 E 3RD ST
PORTAGEVILLE MO
63873-1402
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-5467
  • Fax: 573-379-5671
Mailing address:
  • Phone: 573-379-5467
  • Fax: 573-379-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2001008920
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2001008920
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: