Provider Demographics
NPI:1003842154
Name:PASSANISE, JENNIFER L (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:PASSANISE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STEFFES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-5150
Practice Address - Fax:417-820-5155
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO154827363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicaid
MOQ68505Medicare UPIN