Provider Demographics
NPI:1326407800
Name:MISSOURI MENNONITE CLINIC, LLC
Entity Type:Organization
Organization Name:MISSOURI MENNONITE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNM, APRN/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:VEE
Authorized Official - Last Name:MCHUGH
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, BSN, RN
Authorized Official - Phone:417-616-3114
Mailing Address - Street 1:14093 HOPEWELL RD
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084
Mailing Address - Country:US
Mailing Address - Phone:573-378-5295
Mailing Address - Fax:573-378-5292
Practice Address - Street 1:3840 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-616-3114
Practice Address - Fax:573-378-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207VX0000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty