Healthcare Provider Details

I. General information

NPI: 1053845966
Provider Name (Legal Business Name): JACQUELYN LORRAINE ADDINGTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 BURKARTH RD STE 302
WARRENSBURG MO
64093-3101
US

IV. Provider business mailing address

407 BURKARTH RD STE 302
WARRENSBURG MO
64093-3101
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-5558
  • Fax:
Mailing address:
  • Phone: 660-747-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14-134081-031
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2008021001
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-77571-031
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017001816
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: