1154792810 NPI number — MRS. FAWN ZIMMER FNP

Table of content: MRS. FAWN ZIMMER FNP (NPI 1154792810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154792810 NPI number — MRS. FAWN ZIMMER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIMMER
Provider First Name:
FAWN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154792810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 S BUSINESS HIGHWAY 13
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64067-1515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-330-6426
Provider Business Mailing Address Fax Number:
660-259-2440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 N BISMARK ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORDIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64020-8101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-344-3572
Provider Business Practice Location Address Fax Number:
866-228-4492
Provider Enumeration Date:
10/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP8647 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 2015035378 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420026294 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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