Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 121404 | MO |
NPI | 1003967951 |
---|---|
Provider Name | Glennette Haney |
First Address | West Plains, MO 65775-1100 |
Second Address | Alton, MO 65606-0468 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 05/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
199440758 | (05) | AR |
597843309 | (05) | MO |
S79430 | (02) |