Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | RN 091078 | MO |
NPI | 1003802406 |
---|---|
Provider Name | Beverly Jo Gann |
First Address | Chestnutridge, MO 65630-3021 |
Second Address | Springfield, MO 65803-4306 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2005 |
Last Update Date | 16/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003802406 | (05) | MO |
425443736 | (05) | MO |
P00314636 | RR MEDICARE (01) | |
P46252 | (02) | MO |