Healthcare Provider Details

I. General information

NPI: 1750068953
Provider Name (Legal Business Name): JILL WAAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL GALLATIN APRN

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N SUNSET LN
RAYMORE MO
64083-9402
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax:
Mailing address:
  • Phone: 844-853-8937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023013706
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2018028277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: