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General NPI Number Information
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NPI Number | 1376055004
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Entity Type | Individual
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Provider Name | MRS. JENNY VIVIAN HAWTHORNE
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Gender | Female
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Dates
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Enumeration Date | 11/03/2017
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 8600 MEXICO RD
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City | O FALLON
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State | MO
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Zip | 63366-7507
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Country | US
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Telephone | 636-202-0721
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Fax | 636-600-5041
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Provider Business Mailing Address
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Address Line | 8600 MEXICO RD
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City | O FALLON
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State | MO
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Zip | 63366-7507
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Country | US
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Telephone | 636-202-0721
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 2013031244
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 20180009355
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License Number State | MO
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