Provider Demographics
NPI:1508318692
Name:PATRICK, ATHINA (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:ATHINA
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 MISSOUR AVE
Mailing Address - Street 2:
Mailing Address - City:FT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-1600
Mailing Address - Fax:573-329-0852
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP021931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH14361858OtherCAQH
OHCNP021931OtherNP LICENSE NUMBER
OHMP5011490OtherDEA