1255704599 NPI number — JESSICA E. BOGGS ANP-C

Table of content: MRS. LAURA SUSAN SOFIELD II RN, APN-C (NPI 1083684625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255704599 NPI number — JESSICA E. BOGGS ANP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGGS
Provider First Name:
JESSICA
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLAHA
Provider Other First Name:
JESSICA
Provider Other Middle Name:
E.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255704599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 E MONTCLAIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65807-5076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-8500
Provider Business Practice Location Address Fax Number:
417-820-8532
Provider Enumeration Date:
11/09/2015

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: 363LA2200X , with the licence number:  2015034077 , 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: 1255704599 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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