MEDICARE: ALLISON F BAX FNP

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	163W00000X	Registered Nurse	2006022700	MO
2	363LF0000X	Family Nurse Practitioner	2011023149	MO

General Provider Information

NPI Number	:	1811287642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON F BAX FNP

Provider Business Mailing Address
First Line	:	PO BOX 1107
Second Line	:	HEALTH BRANCH WEST
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-1107
Country	:	US
Telephone Number	:	573-893-7848
Fax Number	:	573-893-1984

Provider Business Practice Location Address
First Line	:	3308 W EDGEWOOD DR
Second Line	:	SUITE B
City	:	JEFFERSON CTY
State	:	MO
Zip	:	65109-6891
Country	:	US
Telephone Number	:	573-893-7848
Fax Number	:	573-893-1984

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

Provider Enumeration Date	:	04/13/2011
Last Update Date	:	06/28/2012

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