=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609520733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA BETH HENGGELER FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2022
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2016 S MAIN ST
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64468-2655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-562-2600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 E SOUTH HILLS DR
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64468-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-562-4304
-----------------------------------------------------
Fax | 660-562-4308
-----------------------------------------------------
=====================================================
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 | 2014026065
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2022005933
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------