Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 154827 | MO |
NPI | 1003842154 |
---|---|
Provider Name | Ms. Jennifer L. Passanise |
First Address | Springfield, MO 65801-2580 |
Second Address | Springfield, MO 65804-2201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
# PENDING | (05) | MO |
Q68505 | (02) | MO |