=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235546490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA GIBBONS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2014
-----------------------------------------------------
Last Update Date | 07/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92 MAIN ST
-----------------------------------------------------
City | CASSVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65625-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-847-5225
-----------------------------------------------------
Fax | 417-847-5425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 505164
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63150-5164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-820-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2014023482
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------