Healthcare Provider Details

I. General information

NPI: 1104935261
Provider Name (Legal Business Name): MARY J BJORNSTAD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 MATTOX DR
SULLIVAN MO
63080-2365
US

IV. Provider business mailing address

965 MATTOX DR
SULLIVAN MO
63080-2365
US

V. Phone/Fax

Practice location:
  • Phone: 573-860-6000
  • Fax: 573-860-6016
Mailing address:
  • Phone: 573-860-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number072682
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: