Healthcare Provider Details

I. General information

NPI: 1750428959
Provider Name (Legal Business Name): AMANDA GRACE VANCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA GRACE SUNDBERG

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 S FREMONT AVE STE 130
SPRINGFIELD MO
65804-2252
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5150
  • Fax: 417-820-5155
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2001018472
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: