=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265753792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORSYTH FAMILY MEDICAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2010
-----------------------------------------------------
Last Update Date | 04/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10726 E HWY 76 STE. G
-----------------------------------------------------
City | FORSYTH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-546-2590
-----------------------------------------------------
Fax | 417-546-2594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1239
-----------------------------------------------------
City | FORSYTH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65653-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-546-2590
-----------------------------------------------------
Fax | 417-546-2594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP / OWNER
-----------------------------------------------------
Name | SHEILA LOUISE WYMAN
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 417-546-2590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 120158
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------