Healthcare Provider Details

I. General information

NPI: 1669843793
Provider Name (Legal Business Name): CYNTHIA DIANE STOCK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 MISSOURI ST
WAVERLY MO
64096
US

IV. Provider business mailing address

825 S BUSINESS HIGHWAY 13
LEXINGTON MO
64067-1515
US

V. Phone/Fax

Practice location:
  • Phone: 660-493-2262
  • Fax:
Mailing address:
  • Phone: 660-259-2440
  • Fax: 660-251-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016006905
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: