Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2021028648 | MO |
NPI | 1003583147 |
---|---|
Provider Name | Crystal Dawn Phipps |
First Address | Mountain View, MO 65548-7200 |
Second Address | Mountain View, MO 65548-7200 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2021 |
Last Update Date | 26/08/2021 |