Healthcare Provider Details

I. General information

NPI: 1710450762
Provider Name (Legal Business Name): AMANDA LEE TREVINO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E EVERGREEN ST
SPRINGFIELD MO
65803-4300
US

IV. Provider business mailing address

3183 E LIBERTY ST
REPUBLIC MO
65738-7826
US

V. Phone/Fax

Practice location:
  • Phone: 417-823-2900
  • Fax: 417-886-2774
Mailing address:
  • Phone: 417-755-6486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018044128
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: