MEDICARE: KATHLEEN JOY PRINNER ACNS-BC

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	364SA2200X	Adult Health Clinical Nurse Specialist	S002282	AR

General Provider Information

NPI Number	:	1386071785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN JOY PRINNER ACNS-BC

Provider Business Mailing Address
First Line	:	PO BOX 958539
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-8539
Country	:	US
Telephone Number	:	870-508-3200
Fax Number	:	870-508-1359

Provider Business Practice Location Address
First Line	:	628 HOSPITAL DR STE 1-A
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-2946
Country	:	US
Telephone Number	:	870-508-3200
Fax Number	:	870-508-1359

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

Provider Enumeration Date	:	09/30/2013
Last Update Date	:	06/10/2021

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