Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LA2200X | Nurse Practitioner - Adult Health | 2017010492 | MO |
N | 363LG0600X | Nurse Practitioner - Gerontology | 2017010492 | MO |
Y | 363LP2300X | Nurse Practitioner - Primary Care | 2017010492 | MO |
NPI | 1073041760 |
---|---|
Provider Name | Amanda Heisel |
First Address | Labadie, MO 63055-1121 |
Second Address | Washington, MO 63090-4700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2017 |
Last Update Date | 17/03/2018 |