=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023637071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY LANE TRUITT RN, BSN, CCRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 04/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MERCY WAY
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-4524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-556-3729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6202 W BUCKEYE DR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-6050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-861-5866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 2015020712
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------