Healthcare Provider Details

I. General information

NPI: 1225692627
Provider Name (Legal Business Name): JACQUIE SANDS AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 INDEPENDENCE SQ
WEST PLAINS MO
65775-4233
US

IV. Provider business mailing address

PO BOX 1100
WEST PLAINS MO
65775-1100
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-1774
  • Fax: 417-256-1754
Mailing address:
  • Phone: 417-256-9111
  • Fax: 417-256-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2017017200
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2017017200
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017017200
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: