1558880799 NPI number — PAIGE DIANE BURRESS FNP-C

Table of content: PAIGE DIANE BURRESS FNP-C (NPI 1558880799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558880799 NPI number — PAIGE DIANE BURRESS FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRESS
Provider First Name:
PAIGE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
PAIGE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558880799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64803-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-347-3649
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
931 E 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-2878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-8688
Provider Business Practice Location Address Fax Number:
417-347-8693
Provider Enumeration Date:
09/19/2017

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: 363L00000X , with the licence number:  2017023499 , 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)





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