Provider Demographics
NPI:1376877381
Name:PHAM, JULIE K (NP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:K
Last Name:PHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 S FREMONT AVE STE 3300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2246
Mailing Address - Country:US
Mailing Address - Phone:417-820-5200
Mailing Address - Fax:214-820-0993
Practice Address - Street 1:2115 S FREMONT AVE STE 3300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2246
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:214-820-0993
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX732590363LA2200X
MO2020024188363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206467703Medicaid
TX206467704Medicaid
TX206467702Medicaid
TX206467705Medicaid
TX206467701Medicaid
TX206467703Medicaid
TXTXB162115Medicare PIN
TX206467702Medicaid
TX206467701Medicaid
TX206467704Medicaid