Healthcare Provider Details

I. General information

NPI: 1558480640
Provider Name (Legal Business Name): DIANA MOREE BURDICK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA MOREE STOUT FNP

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 NORTH FISHER
VERSAILLES MO
65084
US

IV. Provider business mailing address

102 NORTH FISHER
VERSAILLES MO
65084
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-2349
  • Fax: 573-376-2350
Mailing address:
  • Phone: 573-378-2349
  • Fax: 573-376-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number056572
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: