Provider Demographics
NPI:1508902354
Name:WHITAKER, AMY I (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:I
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402
Mailing Address - Country:US
Mailing Address - Phone:573-458-3425
Mailing Address - Fax:573-426-2282
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-364-7545
Practice Address - Fax:573-368-3672
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO064070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428416309Medicaid
MO428416309Medicaid
MOP87998Medicare UPIN