MEDICARE: MRS. PHYLLIS ANN HANSEN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	093219	MO

General Provider Information

NPI Number	:	1366536849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PHYLLIS ANN HANSEN NP

Provider Business Mailing Address
First Line	:	PO BOX 760
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63902-0760
Country	:	US
Telephone Number	:	573-785-1822
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 PHYSICIANS PARK
Second Line	:	SUITE 203
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-3935
Country	:	US
Telephone Number	:	573-686-4750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	05/14/2015

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