=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972112720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY ELIZABETH RICHARDSON WHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2020
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2340 KATY LN
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-290-3293
-----------------------------------------------------
Fax | 877-849-5233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2340 KATY LN
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 722-903-2935
-----------------------------------------------------
Fax | 877-849-5233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 2020023364
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------