Healthcare Provider Details

I. General information

NPI: 1508750274
Provider Name (Legal Business Name): JAMIE MOONEYHAM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

10616 W FARM ROAD 132
BOIS D ARC MO
65612-7122
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax:
Mailing address:
  • Phone: 417-988-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025020703
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: